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Treatment of Headaches. 



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11 an. M cLane Hamilton, M. D. 



LIBRARY OF CONGRESS. 



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UNITED STATES OF AMERICA. 






— THE — 



MODERN TREATMENT 



— OF — 



HEADACHES 







U 



a 



BY — 



/ 

ALLAN McLANE HAMILTON, M. D. 




MAR 23J388 -*; / 









1888. 
GEORGE S. DAVIS, 

DETROIT, MICH. 







Copyrighted by 
GEORGE S. DAVIS. 

1888. 



PREFACE. 

A little book of this character hardly needs a preface. I 
might, however, offer a word of apology for my failure to men- 
tion many remedies, which in the hands of my reader have 
doubtless been of great value in the treatment of this most 
common of ailments. 

I have written these few pages, drawing from my own 
experience, without any great reference to other articles or 
books, and the remedies suggested are those in which I believe. 
I hope imperfect as they are, they may contain here and there 
a serviceable hint. 

Allan McLane Hamilton. 

20 East 29th St., New York. 



INTRODUCTION. 
HEADACHES 

The complex nature of head pain must, to a great 
extent, affect such a thing as exactitude in diagnosis, 
and the multitude of immediate and remote etiological 
factors, and the circumstances of a modifying character 
in such cases, require a survey of the whole domain of 
disease. General symptomology mu c t be regarded, 
and in but few cases can we consider headache as a 
distinct disorder. Head pain is external or internal, 
and due to a variety of influences that affect the sens- 
ory parts either of the scalp, or the contents of the 
cranium. Circulatory variations with resultant modi- 
fications of pressure — either hyperaemic or anaemic — 
the presence of toxic agents, fungus growths, trans- 
mitted irritation from remote centres, malnutrition 
or some grave disease of the fifth nerve; all enter in- 
the production of this most common form of distress. 
No one disputes the fact that extensive disease 
within the skull may exist without headache. When 
we consider the arrangement of the skull and its soft 
parts, we immediately ascribe to the dura an important 
role as a developer of headaches. This membrane con- 
tains a large number of blood vessels and sinuses, and 
whenever hyperemia, or a serious lesion is found where 
there are resisting bony parts, headache is almost a 
certainty. Many headaches, I am sure, are alone due 



to extra-cranial disturbances, notably scalp congestion 
and inflammation, and it is very probable there are 
headaches of an annoying character, which, as Briquet 
and Mills have pointed out, are simply myalgia I am 
clearly of the opinion that many alleged " eye " and 
" uterine " headaches are ordinary myalgic affections 
of the temporal and occipitp-frontalis muscles. 

Location. — The localization of pain is of value 
in determining the nature of headache, but not so 
much as some authors would have us believe. Some 
years ago all vertical headaches were considered 
" uterine," now much sub-occipital pain is supposed to 
be due to pelvic disorders. There is no absolute cer- 
tainty in connecting a headache with this or that 
bodily disorder, so far as its seat is concerned, but a 
study of the accompanying symptoms is of great 
moment, for there is after all, a more or less relative 
connection. It is of importance to study the time of 
appearance, duration, modifying influences, age of the 
patient, and his appearance and behavior. 

The individual is very likely . to be mistaken 
in regard to the seat of his pain, and is disposed to as- 
cribe what may undoubtedly be a superficial pain to 
deeper parts. Wilks says.- " I suppose that one's 
feelings ought not to influence the judgment, other- 
wise it would be thought that the pain is situated in 
the very depths of the brain itself. I once had ah op- 
portunity of testing the power which the individual 
has in discovering the seat of pain. Haying scalded 



my head with steam rising from a pipe to vaporize a 
sick-room, I endeavored to analyse the character of 
the pain which followed, but was unable to discern 
how it differed in kind from the pain of ordinary head- 
ache." This is quite true, and the hyperesthesia of 
many terminal filaments is quite apt to confuse the 
powers of space perception. An intense local pain, on 
the other hand, may appear to be general, as in 
migraine. 

As I have said, the most important pathological 
states which are conducive to headache are those 
which bear relation to the condition of fulness or 
emptiness of the cerebral vessels. As one-fifth of all 
the blood in the body goes to the head, we may ex- 
pect to find important disturbances in function when 
the amount is either greatly increased or modified. 
As results of cardiac excitement or disease, increased 
vascular tension, determinations or hyperaemic states of 
other organs; or exhausting fluxes; we find varieties of 
headache which are known as congestive or ancemic, 
though their distinction is by no means an arbitrary 
one. Certain toxic headaches belong to the first 
order, and neurasthenic ones to the latter. Anaemic 
headaches are often " uterine," and if we mingle the 
clinical and pathological terms we find ourselves 
in a helpless tangle. I prefer a different classification, 
which is the following: 

i. Congestive headaches. 

2. Anaemic headaches. 



— 4 — 

3. Organic headaches (as a rule due to struc- 
tural cerebral changes). 

4. Toxic headaches (e. g. lithaemic, ursemic, ma- 
larial, et al.) 

5. Neuralgic headaches. 

6. Neurasthenic headaches. 



CHAPTER I. 

CONGESTIVE HEADACHES. 

Under this head come two forms: (a) that in 
which there is a general cerebral congestion and pain; 
(b) that which begins at least in one-sided pain, with 
lateral hyperemia. Its forms are numerous and its 
causes very extensive. No age is free from it and it is 
perhaps the most common of all headaches. Generally 
speaking it is accompanied by a subjective sense of 
fullness, by more or lesss psychic hyperesthesia at 
one time, and dulness at another; by confusion of 
ideas; throbbing and distension of the temporal ves- 
sels, suffusion of the skin, injection of the conjunctiva 
and sometimes of the sclerotics. Brilliancy of the eyes, 
or a lack-lustre expression, and a tendency to sleep, 
diffused pain, which causes the patient to declare 
that his head is encircled in an iron band, or that " it 
feels as if it would burst," are the sensorial disorders. 
It may occur quite suddenly in the course of an attack 
of indigestion, or gradually develope in the person who 
has suffered from obstinate constipation for a few 
days. In point of duration it may last for several 
days, or be almost continuous during the existence of 
an exciting cause. 

In its familiar form it may result from want of 
sleep, a late supper, or a debauch, in which event 
it is often matutinal, and is associated usually with 



— 6 — 

nausea and what the Germans call " katzenjammer," a 
sense of intolerable "seediness." The eructations or 
emissions from the stomach are quite apt to be in- 
tensely acid, and there is besides the diffused pain, a 
peculiar weight above the brows. 

The treatment for such a headache is, first a good 
brisk saline purgative, such as Hunyadi water, 
Friedreichsalle, or a solution of Crab Orchard salts; 
a cold bath and douche, and the use of the diffusible 
stimulants. I have given many of my patients the 
following: 

1$ Spts. ammon. aromatici, § ii. 

Coca hydrochloras, gr. x. 

Ammon. bromidi., § iss. 

Aquae camphorse, ad § iv. 
M. Sig. — One teaspoonful in iced water to be repeated 
hourly until relief is obtained. 

In some cases an aromatic bitter tonic and car- 
minative will relieve the patient if his headache be due 
to alcoholic excesses: 

$ Tr. Nucis vomicae, 

Tr. Capsici, aa 3 iiss. 

Tr. Gentianae Co., § ii. 
M. Slg. — One teaspoonful in water at a dose. 

These headaches, especially if there be gastric 
derangement, are helped by effervescing drinks. Here 
is a domestic prescription which is a valuable one. 
The juice of one-half a lemon in a pint of cold apol- 
linaris water. 



There is a form of congestive headache due to 
exposure to the sun, which is accompanied by dizzi-. 
ness, constipation and some confusion of the mental 
operations, and a great sense of prostration. The 
headache is not so intense as some others, but it is 
low, continuous and "muttering." With it is either 
an irregular fluttering, or a slow small hard pulse. 
There is a passive hyperemia of the brain, notwith- 
standing the fact that there is pallor. Under such 
circumstances the improvement of the heart's action 
will do more for the sufferer than local remedies. 
Digitalis in increasing doses, its administration being 
guided by the behavior of the patient, ice bags to the 
back of the neck and diffusible stimulants, such as 
ammonia or alcohol are the indications. Cold douches 
to the head, and the application of heat to distant 
parts may also be required. 

A congestive headache due to insolation of an 
active type, is often benefitted by aconite in small and 
repeated doses, or veratrum viride either in combina- 
tion with the bromides or alone. 

There is an imperfectly developed congestive 
headache that may occur in anaemic patients, as 
the result of head work.* Wood thus speaks of this 
form of trouble; "headache is another of those fortun- 
ate symptoms which are of a character to make them- 
selves so felt as to force the attention of the brain 



■Brain-work and over- work, p. 125. 



worker. The head is often the seat of unpleasant 
sensations which are not headache, but which, as the 
signs of mental over-driving, are of even more serious 
meaning than is headache. Such are a sense of 
weight on the top of the head, a feeling of constric- 
tion of the forehead, or a more general cephalic dis- 
tress. Such phenomena occurring after long con- 
tinued strain, are very significant and should always 
be heeded." This form of suffering, is as a rule, 
associated with insomnia, lassitude, inability at con- 
centration, great depression and irritabilility, and 
often by actual pain. The headache is always most 
aggravating after hard work, a long day in court, the 
preparation of a sermon, or speech, a difficult case or 
a sleepless night. I have met with a variety of head- 
ache in men between forty and fifty, in which profuse 
discharge of limpid urine, and some irregularity of 
heart action betoken a profound impression made 
upon the sympathetic nervous system. As in other 
headaches of the congestive type, dizziness, pulsating 
carotids, tinnitus muscae volitantes and contracted 
pupils are often recognized. 

Sub-occipital headache of a sympathetic type is 
also not uncommon among brain workers, and is un- 
doubtedly due to some hyperemia of posterior cere- 
bral parts due to the inefficient action of the vaso- 
motor nerves governing the vertebral arteries. 

Woakes * describes a form of congestive occipital 

* London Practitioner, 1878 p. 262. 



— 9 — 

headaches, attended by feebleness of the arms, running 
at the eyes and nose, blueness and coldness of hands, 
and at the end of an hour culminating in an attack of 
vomiting. Two hours after the onset of the sub-occi- 
pital pain there were superadded general pains of the 
back and neck and great prostration. The symp- 
toms Woakes compares to those of mild poisoning by 
tobacco, but there was no vertigo. The patient had 
been subject to migraine for several years and was 
weak, sallow and emaciated. Camphor, or ice held in 
the mouth would cut the attack short. This author 
is inclined to believe this form of sub-occipital head- 
ache a sympathetic disorder, and due to reflex irritation 
of the gastric branches of the pneumo-gastric and to 
dilatation of the vertebral artery. This patient's neck 
was painted with a strong solution of camphor and 
the headache was speedily relieved. 

The cutaneous nerves at the back of the head which 
are brought into relation with the ganglia through the 
medium of the plexus of the vertebral artery doubt- 
less, when stimulated by the external application, pro- 
duced contraction of the blood-vessels. 

In headache due to overwork it will, of course, 
be suggested to every intelligent physician to reg- 
ulate his patient's mode of life; to advise rest and 
recreation, and prescribe remedies directed to reg- 
ulate the cerebral circulation, and improve the nutrition 
of the nervous tissue. Irregularity of intellectual work 
is perhaps more conducive to headache of this kind 



— io 

and cerebral exhaustion than anything else. The 
hyperemia of the brain which is brought about by 
abnormal use of that organ is eventually succeeded by 
capillary dilatation, and a passive condition takes the 
place of an active one. Working under pressure, or 
at hours when one's fellows are abed is to be depre- 
cated. So, too irregularity of mental habits, improper 
care of the stomach, and the fictitious aid of to- 
bacco and stimulants are at the bottom of much 
trouble. One of the worst headaches I ever knew was in 
the person of an editor who ate a hearty supper, com- 
menced his labors shortly thereafter, and at ten o'clock 
drank a pint of strong black coffee he nightly made 
in a bigen in his office. 

Such patients need the phosphates, and are more 
benefited by these preparations than any other. The 
judicious addition of remedies which improve vascular 
tone, such as nux-vomica and its derivatives is coun- 
selled. 

I. append a number of formulae: 

B Strychnine sulph., gr. i, 
Cinchon. sulph, 3 i, 
Acid phosphorici dil. 
Syr. limonis, aa § ii 

M. Sig. — 3 i in water after eating. 

This combination occasionally produces gastric 
trouble and I then use the following in preference: 



— II — 

Ijt Tr. nucis vomica 
Glycerinae, aa § ss. 
Acid phosphorici dil. 
Syr. zingib, aa § ii. 

M. Sig. — 3 i in water after eating. 

In many cases there is a great deal of cardiac 
weakness when the habitual use of small doses of ni- 
tro-glycerine (gr. -J^) morning and night do good. 
For such patients I have also employed a pill which is 
the following: 

5 Zinci phosphidi, gr. iv, 

Ext. physostigma venenos, gr. xii, 
Ext. gentianae, gr. xlviii. 
M. Sig. — Ft massae et divid in pillulae No. xlviii. 

Sig. — One after each meal. 

This combination is indicated especially when 
there is a suspicion of mental trouble or impending 
central disease as is the following: 

5 Tr. digitalis, § ss, 

Syr. hypophosphiti Co., § viii. 
(Fellows'.) 

M. Sig. — One to two teaspoonsful thrice daily. 

The improvement of surface circulation in con- 
gestive headaches due to brain exhaustion is a prime 
necessity. Morning bathing in water colder than the 
body to which sea salt has been added, is to be ad- 
vised, and I have been in the habit of using an artifi- 
cial salt made by Mr. R. Fingertmt, cor. 28th st. and 



12 

4th ave., New York, which contains a large amount of 
potash and oxide of iron in combination. One pack- 
age of this salt is to be placed in a bath-tub of warm 
water 'in which the patient is to remain ten minutes 
before retiring. 

For the immediate relief of the headaches I rely 
upon cold applications and sub-occipital cupping; ab- 
solute rest and quiet. Occasionally, a large dose of 
the bromide of potash does good, and in those ex- 
citable cases when the hyperemia takes place in an 
ordinarily anaemic brain it is especially good. Foth- 
ergill in his admirable paper in the West Riding re- 
ports has fully explained the philosophy of this form 
of hyperaemia, which he believes to be due to cell ir- 
ritability. 

The use of chloroform is very popular with Eng- 
lish practitioners, and Day recommends it in the con- 
gestive headaches of aged people. 

The following is one of his formulae, which I 
have used for several years. 

5 Spts. chloroform, TTLv, 

Liq. ergotae ext., ff|,xx — 3 ss, 
Aquae purse, ad § i. 

M. Sig. — To be taken three times a day. 

The congestive headaches of school children are 
not only due to over- work but to gastric and intestinal 
causes. The appearance of the child is characteristic, 
and abundant evidences of cutaneous suffusion are 



— I 



present. The headaches are throbbing, accompanied 
by irasciblity, and are worse after eating, or towards 
the latter part of the day. Bad dreams, night terrors 
and a clouding of brain action are accompaniments, 
and such children are apt to be dull at school, or uneven 
in their capacity. Sometimes we find them to be of 
the neurotic temperament so graphically described by 
Maudsley. They are usually bright in some things 
and very stupid in others. In some cases the head- 
aches which are always aggravated by digestive dis- 
turbances and confinement in school, are the precur- 
sors of more aggravated cerebral mischief, and even of 
tubercular meningitis. They are best treated by 
anaemiants such as the bromides. A combination of 
the bromides is excellent, and the largest dose may 
be given at bedtime: 

1$ Sodii bromidi, 
Potass, bromidi, 
Ammon. bromidi, 
Calcii bomidi, aa 3 ss. 
Syr. Rubri, § ij. 

Sig. — One to three teaspoonsful in water, thrice daily or 
when needed. 

Removal from school, gymnastic exercises, salt 
bathing and open air exercise are of the utmost im- 
portance, and it will be found that if some prepara- 
tion of phosphorous is given at the same time, much 
good will result. I think in many cases iron is con- 
traindicated, and it not only increases the headache, 



— i 4 — 

but disturbs the already impaired digestion. When it 
is given it should be in some assimilable form. The 
syrup of the iodide is the best of these, and in com- 
bination with cod-liver oil we very promptly see its 
good effects. 

^ Syr. Ferri iodidi, § ss. 
01. Morrhuse, ^iiiss. 
M. Sig. — 3 ij to § ss, t. i. d. 

In some cases of headaches in children the use of 
the syrup of the bromide of nickel is recommended. 
It is best prepared by the combination of carbonate of 
nickel with dilute hydrobromic acid, and five grains 
should be contained in each teaspoonful of syrup. 
This is especially beneficial when there is much rest- 
lessness and emotional activity. Many headaches of 
early life are due to injudicious diet, and especially to 
the consumption of large quantities of meat. The 
influence of a preponderating nitrogenous diet has 
been shown to increase the number and frequency of 
epileptic paroxysms, and I have repeatedly witnessed 
its bad influence in the development, not only of dis- 
turbed sleep, but hysteria, and congestive headache. 

The headaches which are so often connected with 
cardiac hypertrophy and renal, disease, are common, 
especially in middle aged persons. , I have already 
spoken of a passive variety, but there is an active 
form as well which is associated from time to time 
with conditions .in which the arterial tension is sud- 



— i5 — 
denly increased from even slight causes. In winter, 
especially when the cutaneous circulation is poor, we 
find that these subjects are most often troubled, and 
attacks of head pain are common in persons who eat 
and drink to excess, and take little or no exercise. 
The possessors of such congestive headaches present 
facial evidence of cutaneous engorgement, amounting 
often to a purple suffusion, acne and dilated capil- 
laries. The pulse is hard and full and the urine is 
scant and loaded with phosphates or urates. Slight 
exertion is followed by great fatigue, and the head- 
aches are dull, throbbing and often preceded by 
drowsiness. The head pain is often attended by cos- 
tiveness, and relieved by purgation. The general 
state of the patient must be attended to. Blue pill 
and colocynth are both excellent, and have a tradi- 
tional reputation which has not been diminished by 
time, and has been handed down by our port-drinking 
ancestors. A capsule like the following may be given 
occasionally at night. 

]£ Hydrarg. massae, 

Ext. colocynthii., 

Ext. fel. bovis., aa 3 i. 
M. Divide in capsular No. xv. 
Sig. One or two at night. 
Or, 
fy Podophyllin, gr, i. 

Hydrarg. massae, 3 i. 

Ext. nucis vomicae, gr. iii. .^ 

M. Divide in pillulae No. xii. 
Sig. One at night when required. 



— i6 — 

An excellent pill for the relief of the intestinal 
condition, especially when the headaches are attended 
with drowsiness and depression of spirit is the follow- 
ing: 

1£ Ext. nucis vom., gr. vi. 

Hydrarg. chlor. mite., gr. vi. 
Ext. Hyoscyamiae, 
Pulv. ferri. exissicatis, 
Pulv. aloes, aa gr. xxiv. 

Ft. massae et divide in pillulae No. xxiv. M. 
Sig. One every other night. 

Lemaire-Picquot, and Bartholowboth speak highly 
of arsenic in congestive headache. The former was 
the first to suggest its use in those cases where the 
signs of atheromatous change were visible, and when 
there was drowsiness and other symptoms dependent 
upon loaded vessels. 

The use of small, repeated doses of calomel, say 
one-half grain nightly, relieves hepatic congestion, 
and if it is followed up by Sprudel salts in the morn- 
ing its efficacy will be much increased. 

Some patients of this class do well on the saline 
waters, Hunyadi Janos, or Mattoni. 

For the relief of the headaches themselves a 
variety of remedies have been suggested. Ergot 
and the bromides rank high as cerebral anae- 
miants. These two remedies should not be given 
together under any circumstances. The aqueous ex- 
tract is preferable to any other form of ergot, and does 



— 17 — 

not derange the digestion. An active and convenient 
preparation is the ergotin of Bonjean, but it is more 
expensive than the American aqueous extract and no 
more efficacious. 

The combination of aconite with other remedies 
of this class is advisable, provided there be no decided 
cardiac disease, and I have used the following with 
success: 

]$ Sodii bromidi., 

Ammon. bromidi., a,a § ss. 

Chloral, hydratis, 3 ii. 

Tr. aconiti rad., 3 iss. 

Aquae menth. pip., ad § iv. 
M. 
Sig. A teaspoonful twice daily, or oftener if required. 

Some congestive headaches in elderly people are 

probably in great part meningeal, and ergot under 

such circumstances is to be at once tried. Its action 

is prompt, and I have never seen anything worse than 

gastric derangement in consequence of its extended^ 

use. 

In congestive meningeal headaches, and these 

are often exhibited by great muscular restlessness men- 
tal confusion, injection of the eyeballs, belladonna is 
a valuable remedy. The following prescription is- 
worthy of an extended trial : 

5 Tr. Belladonnas, 3 ii. 
Potass, iodidi, 3 vi. 

Aquas anisi, §" iv. 
M. 
Sig. One teaspoonful in a wineglassful of Vichy water 

after each meal. 
3 R 



— iX — 

The doses should be increased as tolerance is 
established. 

Dr. Wm. C. Glasgow, * of St. Louis, has called 
attention to a very ingenious system of treatment 
which is of service in congestive headaches of a fami- 
liar kind, viz: the abstraction of blood by pricking the 
cavernous bodies and relief of the constriction. Dr. 
Glasgow speaks of his experience as follows: "The dis- 
turbing cause (vascular distension) is seen in the 
frontal headache brow-ache, or so called catarrhal 
headache radiating from the root of the nose; it may 
be limited to the forehead; it may be felt as a dull, 
throbbing pain in the temples; it may give rise to in- 
tense dull ocular pain, or, extending over the head, it 
may be felt in the occipital region occuring frequently 
from cold or exposure. We also find it often con- 
joined with certain vaso-motor disturbances of the 
mucous membrane. It is frequent at the menstrual 
epoch, coincident with the turgescence of the cavern- 
ous bodies and is the cause of many of the so-called 
nervous headaches, or uterine headaches with which a 
similar condition of the cavernous body will be found. 
If we examine the nasal chamber during the attack of 
congestive headache, we shall find the cavernous 
bodies in a state of tension; they may not be greatly 
swollen or enlarged, but to the eye the condition of 
the mucous membrane is that of tension and fulness. 



* N. Y. New Jour., Sept. 3, 1887. 



— J 9 — 

The degree of tension corresponds in measure with 
the severity of the headache. 

" A few years ago I treated those cases with hot 
alkaline sprays, gently applied, and the use of hot 
fomentations combined with the use of the usual con- 
stitutional remedies. This mode of treatment has not 
been altogether satisfactory and during the past four 
years I have substituted for it the local abstraction of 
blood, for which I can allege unqualified success. 

A simple bleeding may relieve the headache, or it 
may have to be repeated in a day, a week, or a month. 
I have seen but four cases which were not perma- 
nently relieved by a bleeding repeated from two to six 
times. * * ■ * To produce the bleeding 
no cut is required, the cavernous body is simply 
pinched and the blood flows freely until the tension 
has been reduced; then it ceases. The amount of 
blood drawn rarely exceeds one ounce. In many 
cases it is less than this, and in many cases a single 
drachm of blood removed will give the required relief. 
In cases of extreme congestion the flow will equal 
several ounces before it ceases. The quantity of 
blood being dependent upon the distention of the ves- 
sels and this corresponds with the severity of the 
symptoms." 

One of the most common forms of headache is 
that known as migraine, and two varieties are recog- 
nized with reference to the pathological states which 



20 

give it origin. The form that now interests us is the 
angio-paretic. It is a clearly nervous headache, and 
one of a sympathetic nature. The subjects of such 
headache are usually those who inherit some neurotic 
tendency, and I have known of several generations of 
the same family who have been victims. Not infre- 
quently is it associated with epilepsy, and if we go 
back into the family history we may find a history of 
phthisis, insanity or various disorders of the pulmon- 
ary or nervous systems. A large portion of the cases 
are women, and it seems to bear some relation to the 
menstrual periods, being worse with dysmenorrhcea, 
and often ceases, even in bad cases, with the arrival of 
the menopause. It is a unilateral headache affecting 
more often the left side of the head than the right, 
and is more or less sudden in its development, so far 
as the attack is concerned. The patient may feel a 
sense of malaise or languor and a chilliness and 
drowsiness, and shortly afterwards a smart twinge of 
supra-orbital pain. Others follow, and the face, which 
was perhaps pallid, becomes red and congested. The 
pain may invade one side of the head alone for a 
time, but eventually involves the whole head 
so that both sides are affected. The pain is 
intense when established; throbbing, burning and 
insupportable. The eyes are bright and suf- 
fused, the bodily temperature is sometimes elevated, 
and the patient is restless and excited. Darkness re- 
lieves to some extent the photophobia, and the most 



21 



secluded and quiet spot is sought. Every noise in- 
tensifies the patient's sufferings, and the jar of a pass- 
ing wagon, or a noisily closed door disturbs him. 
After a variable period of suffering, the continuity of 
the pain is broken or it again becomes paroxysmal, or 
muttering, like the thunder at the end of a storm. At 
this time nausea may occur, and the patient more or 
less successfully empties his stomach. It is a mistake 
to suppose that this symptom indicates that the di- 
destive organs are necessarily at fault. Though such 
headaches have been called "sick headaches" they 
are not as a matter of course due to the condition of 
the stomach, and it is probable that this symptom 
originates from an irritation of the pneumogastric. 
The headaches often bear no relation to the state of 
digestion — they come after or before a meal or when 
digestion is most perfect. There is a tendency in 
migraine to chronicity, and attacks may occur daily. 
The pathological state is an unequal paresis of the 
muscular fibres of the vessel coats and the repeated 
attacks lead to a varicose condition, and possibly to 
miliary aneurisms. 

In the treatment of this form of congestive head- 
ache two indications present themselves: i. The 
improvement of the general system. 2. The relief 
of the attack itself. The migrainous patient is often an 
anaemic individual, and the anaemia is of that kind 
which is the most troublesome. There is often a dis- 
position to make fat, and a tax upon the nervous sys- 



22 

tern, which directs the function of the sympathetic 
nervous system into other directions. There is a vast 
amount of useless tissue that demands blood that is 
needed elsewhere and the balance of vascular tension 
is constantly interrupted — one moment the brain 
is anaemic, the next congested. The cerebral vaso- 
motor nerves lose their tonus and a condition of un- 
equal angio-paresis occurs. Such patients need iron 
and digitalis, tri-nitrine or strophanthus. 

In the relief of the headaches themselves we may 
resort to diffusible stimulants, and I have for many 
years resorted to the treatment, which consists in the 
administration of large and repeated doses of the 
muriate of ammonia — 20-grain powders should be pre- 
pared and these should be given in a large quantity of 
water every hour until the headache is broken up. 
Some patients are relieved by repeated large draughts 
of green tea, or black coffee. Effervescing draughts 
of bromo-caffeine act in much the same way. 

Bearing in mind the irritability of the brain in 
such cases and the existence of the headaches as a re- 
lation to epilepsy - it may be well to resort to the bro- 
mides. The use of this class of drugs should be con- 
tinuous and without relation to the actual occurrence 
of attacks. Large doses may be given thrice daily, 
and do more good than their irregular administration; 
or, if the attacks are periodical, with reference to the 
time of the seizures. Chloral hydrate may be com- 
bined with the bromides but care must be taken not to 
form the habits of chloralism. 



]$ Sodii bromidi, § iss. 

Chloral, hydratis, 3 vi. 

Aquas anisi, § iv. 
M. Sig. — One teaspoonful in water morning and night. 

The vascular tonus should be improved, and ar- 
senic either in combination with strychnine or quinia 
is apt to help the patient and destroy the migrainous 
habit. This is Routh's * formula which is also excel- 
lent in malarial headaches. 

1$ Quinia disulph., 3 ss. 
Acidi Arseniosi, gr. i. 
Acidi nitrici dil., 3 i. 
Aqua; purse, ad § i. 

M. Sig. — Gtts xxx in a wineglassful of water after eating. 

Elderly women at the time of the menopause are 
often affected with a peculiar congestive headache 
which seems to be connected in some way with the 
" flashes," which are so often the subject of complaint. 
The pain is often vertical and throbbing, and in some 
individuals is attended by very great depression of 
spirits. 

Such headaches are relieved by agents which 
quiet pelvic irritability. Warm douches repeated twice 
or thrice daily are of benefit, and I have been in the 
habit of administering large doses of dilute hydro- 
bromic acid or Fothergill's solution, which is made by 
the addition of tartaric acid to a solution of bromide 



Day on Headaches. 



— 24 — 

of potash. This should be well diluted, and from half 
an ounce to an ounce is sometimes required to bring 
relief. The use of the mustard foot bath, brisk ex- 
ercise and massage are often necessary as adjuvants. 
These headaches are often helped by the compound 
spirits of ether. 

Sexual excitement of a protracted kind without gra- 
tification, or what Fox calls "mental onanism," is apt 
to result in a variety of headache of a sympathetic 
nature and with all the evidences of congestion. The 
head pain is short lived, closely follows the cause, 
and is easily relieved by rest and quiet, and a large 
dose of any one of the bromides. I have often met 
with this variety in patients suffering from incipient 
insanity of the masturbatic type. Such young people 
are apt to present rather lively emotional excitement, 
and to be boastful and conceited at times. The pain 
is frontal, and accompanied by a sense of supraorbital 
pressure. 

Spinal douches consisting either of a jet of cold 
water or sponging tend to arouse the dormant viscera 
and equalize the distribution of blood. Warm foot 
baths are of course excellent auxiliaries to other 
remedies in the acute attack. Turkish and Russian 
-baths though admirable remedial agents are danger- 
ous and should be used with the greatest caution. I 
have known of several deaths as a result of their in- 
judicious use, and if .there is the least suspicion of 
atheromatous degeneration or cardiac disease they 
should be forbidden. 



— 25 — 

As to mineral baths and water, there is much to 
be said which is, however, found in special works 
upon baleonology. The Canadian and American 
springs best suited for the treatment of cerebral con- 
gestion, notably the passive variety, are those at 
St. Leon near Quebec; Caledonia near Ottawa; St. 
Catherines; Richfield; Sharon and Saratoga in New 
York State; Buffalo Lithia Springs, Virginia; the 
Berkeley Springs, and the Red Sulphur Springs, Va.; 
Spring Lake Well, Ottawa Co., Mich.; the Wisconsin 
Springs (Waukesha, etc.). The foreign springs which 
are especially serviceable are: Vals and Vichy, 
(Grande Grille) France; Salzbrun, Freiburg, Hom- 
bourg, Carlsbad, Aix la ChapeMe, Baden Baden; 
Friedrichshall, Kissengen, Marienbad, Seidlitz and 
Adelheidsquelle, Germany, and Leamington and Chel- 
tenham in England. There are many others, but this 
list I think is sufficient. 

In congestive headache, especially passive, do I ad- 
vise the use of saline purgative waters and baths. It 
is better to give some of the stronger German or 
Hungarian waters than to allow the patient to flush 
himself with the milder aperients — Congress water 
and the like, and those which should be used in great 
moderation. The waters of Carlsbad or its evapor- 
ated salt, which is now for sale, while not so good as 
Hunyadi or Rubinat, are excellent alteratives. Pullna 
water heated or cold is especially beneficial in those 
headaches where there is much venous turgesence of 
the face. 



— 26 — 

The constant use of baths and douches of well 
regulated temperature is all important. A cold bath 
of brief duration for the purpose of stimulating the 
surface capillaries is a prime necessity. Better than 
the immersion of the whole body is the use of the 
douche or needle bath. In the absence of elaborate 
apparatus we may employ the ordinary " rose spray " 
and a rubber tube fitted to the cold water cock. Fig. 
i is an elaborate needle bath made by John Sim- 
mons, no Centre St., New York, which is perhaps 
better suited to hospitals than private houses. At a 
small expense, however, a practicable needle bath may 
be constructed and its therapeutical advantages will 
fully warrant a moderate outlay. 

The diet of the patient who suffers from these 
headaches should be simple, and as a rule, consist of 
a reduced quantity of the hydro-carbons. It is a mis- 
take to err in going to the extreme of entirely abolish- 
ing, as is too often the custom, certain articles which 
are not positively injurious. It should be our aim to re- 
duce the labor of the digestive organs, and, therefore, 
it is better to give small quantities of well digested 
food frequently, than large quantities at long inter- 
vals. Lean meat, poultry, game, fish, eggs, the green 
vegetables, and stale bread, agree with persons sub- 
ject to congestive headache, as a rule, better than 
articles of diet containing much starch or fat. Veal 
and pork and the watery or aromatic vegetables are 
to be dispensed with, as are all substance which are 




*egsast- 



Fig. i. Apparatus for Needle Bath. 



— 28 — 

slow of digestion. Tea and coffee are not as harmful 
articles as they are generally supposed to be, though 
of course in some instances they must be rigorously 
excluded. 

Alcohol in some cases of congestive headache is 
absolutely necessary, though of course in others it is 
directly contraindicated. The passive hyperaemic 
headaches are certainly benefitted, and if the stimu- 
lant selected is a proper one, I can see every reason 
why it should be allowed. Brandy, Rum, Burgundy, 
Champagne, Port and Sherry wine, malt beverages 
and the liqueurs, are harmful under all circumstances, 
but light wines and whiskey or gin in regulated quan- 
tities, in angio-paretic conditions do much to improve 
the vascular tonus. In the headaches of middle or 
old age, they are nearly always of great service. 

There are many palliatives which may be resort- 
ed to for the external relief of congestive headaches. 
Cold applied to the nucha, or to the top of the head 
by means of ice-bags; cold douches and ether spray to 
the temples are useful. 

Benham in an excellent article (West Riding Re- 
ports, vol. iv, p. 152,) refers to the mechanism of cold 
as follows: " It may be that the decreased tempera- 
ture and consequent lessened nerve sensibility pro- 
duced by the cold upon the extremities of the sensory 
nerves, are shared in somewhat by the centres under 
the cranium, from which they spring; and thus it may 
be that that portion of the sensorium to which the irri- 



— 2 9 — 

tation on the nerve peripheries in the stomach or else- 
where — causing headache — is conveyed, shares in the 
diminished sensibility of those centres, and is therefore 
less capable of receiving impressions as vividly as be- 
fore; the sensation of pain felt by the patient being 
consequently much lessened. When we consider the 
proximity of the central tracts of the fifth, and the 
pneumogastric branch of the eighth pairs of nerves, it 
seems probable that cold applied to those peripheries 
of the fifth distributed over the forehead should pro- 
duce such an effect in parts in close proximity to the 
origin of the pneumogastric as to be capable of some- 
what modifying the impression in the course of its 
transmission to the sensorium from the peripheries of 
that nerve irritated by a disordered stomach." It 
should be born in mind that in some cases of con- 
gestive headache the headaches are increased instead 
of benefitted by a too extensive application or a too 
intense degree of cold. 

I have been in the habit lately of using pressure by 
means of compressed sponges. These may be had of 
most apothecaries and are about one-half inch thick 
when dried. One sponge is to be applied over .either 
temple, and both are held in place by a bandage 
passed several times around the head and firmly 
fastened. When this is secured, water may be applied, 
and when the sponges expand, steady and even pres- 
sure is made upon the temporal vessels. Many con- 
gestive headaches are simply due to hyperaemia of the 



— 3° — 

scalp, and this limitation of blood supply is often fol- 
lowed by prompt relief of the pain. The use of caro- 
tid pressure by Coming's method also produces tem- 
porary relief, and in certain frontal headaches firm 
pressure applied on the root of the nose is an imme- 
diate palliative. 

External stimulating or irritant liniments do little 
or no good and only produce redness or vesication, 
except when the headache- is of the kind just mention- 
ed. Menthol applied in the form, of cones sometimes 
relieves the head pain, but it is a temporary and uncer- 
tain remedy at best employed in this way. An alco- 
holic or etherial solution used -with the atomizer is far 
preferable. 

Bearing in mind the physiological operation that 
follows the irritation of the cervical sympathetic or 
the upper part of the cord, recourse may be had 
sometimes to the actual cautery or blister for the pur- 
pose of effecting local revulsive action of a sharp and 
limited nature. 

The well-known action of the galvanic current 
upon the sympathetic nervous system suggests its use 
in congestive states of the cerebrum. The cathode 
may be placed on the superior cervical ganglion of 
the cervical sympathetic, and the anode on the fore- 
head. Very mild currents from two or three cells are 
sufficient, and under all circumstances the operation 
should be conducted with great care. Electrical irri- 
tation of the sympathetic ganglia is known to produce 



_ 3 I — 

contraction of involuntary muscular fibre, and the 
rationale of its effects in cerebral hyperemia will 
be apparent. The application should last but a min- 
ute or two. It may also be made by means of large 
sponge — or cotton — covered electrodes one being 
placed upon the top of the head and the other at the 
back of the neck. Sub-occipital headaches are de- 
cidedly relieved in this way. 

Faradism is of benefit in headaches which are due 
to congestion of the scalp, or when the object sought 
is the relief of internal pain by the reflex irritation 
of cutaneous filaments. Great care should be taken 
not to interrupt the galvanic current, and I would 
urgently recommend the use of the water or wire 
rheostat. 

The improvement of the surroundings of the suf- 
ferer from habitual headaches is a part of the duty of 
the careful practitioner, for there are many patients 
whose trouble does not yield to medicines but is con- 
stantly aggravated by local causes. Many a conges- 
tive headache is due to bad heating and ventilation. 
Furnace heat, weather strips, and windows rarely 
opened in winter, together with bad plumbing, are 
responsible for much misery. Injudicously selected 
clothing, sedentary habits, and irregular hours contri- 
bute their share, and often the individual selects a 
dwelling place which is entirely unsuited to his state 
of health. A low altitude, where the temperature and 
barometric pressure are not high, agrees with most of 



— 32 — 

the victims of cerebral congestion, or headaches due 
to such a pathological condition; and mountainous 
districts are to be avoided as places of prolonged 
residence. 



CHAPTER II. 

AN/EMIC HEADACHES. 

Cerebral anaemia is far more common among 1 
women than men, and in a very large number of 
instances is a feature of the depressed condition of the 
nervous system dependent upon loss of blood, and 
uterine disorder. In others, it is due to loss of blood 
from hemorrhoidal fluxes, general malnutrition, and 
debilitating causes of many kinds. It is confined to no 
age, but is usually most pronounced in women during: 
the catamenial years. 

The anaemic headache is rarely continuous, though 
in some individuals, it exists in a dull unpronounced- 
form with occasional exacerbations of decided pain. 
It is accompained by a sense of very great vertical 
pressure and throbbing. At times it is associated with 
neuralgia of the fifth nerve. The patient is pallid, has 
enlarged pupils, a small weak pulse, pale lips and 
buccal mucous membrane. The tongue is apt to be 
indented, furred and pale. Digestion is weak, and 
palpitation common. An aortic murmur is often 
heard, the sphygmographic tracing is almost straight; 
and the number of red corpuscles is greatly reduced. 

Cold clammy hands and feet, phosphatic or limpid 
urine, great muscular fatigue, and insomnia are char- 
acteristic. In many individuals there is decided ten- 
4 r 



— 34 — 

derness of the spinous processes and the vertebra 
prominens is especially tender. 

In some women these headaches occur with great 
mental depression just after the menstrual period, and 
this is especially the case where there is menorrhagia. 
They often recur daily, and in patients under treat- 
ment, where iron is given, and the uterine condition 
not improved, it will be found that just before the 
menstrual period, and when some recuperation has 
taken place, that there is a marked diminution in the 
character and severity of the attacks, with subsequent 
relapse however. 

The anaemic headache is more pronounced in the 
early part of the day. In fact the patient commonly 
awakens with some nausea and head distress. This 
may often be abated by a cup of hot strong tea, or 
.ammonia in some form. 

Fothergill, in writing of anaemic headache, says 
in one of his early contributions: "The pain is dull, 
persistent and unvarying, and the sensation is not un- 
commonly as if the skull was opening, or the upper 
half of the calvarium was being lifted off. Chronic head- 
ache in conditions of cerebral anaemia is usually, or at 
least often, vertical; while frontal headache is rather 
associated with passing conditions of exhaustion from 
sustained intellectual labor. The why of this will be 
seen presently. 

Vertical headache is most distinctly associated 
with anaemic conditions of asthenic gouty states, and 



— 35 — 

is often of much diagnostic value, often, also, point- 
ing very clearly the direction which our therapeutic 
measures must take if we wish them to be successful. 
At other times headache, often vertical, sometimes 
frontal, is found along with those anaemic states when 
the patient complains chiefly of " low spirits," simple 
states of mental depression and unhappiness, from a 
defective blood supply to the encephalon." 

The bromides and chloral are useless and 
aggravating remedies in such forms of headache and 
should never be given. In some cases of anaemic 
headache when the seizure is unilateral, in fact when 
we- have an angino-spastic migraine, the use of 
bromide is indicated, but only then. I much prefer 
cannabis indica which may be given in pill form in 
increasing doses, commencing with one-eighth of a 
grain of the extract, and increasing until mild toxic 
effects are reached. When such headaches occur 
about the menstrual period a mixture of the bromide 
and cannabis indica is an excellent one. • 

^ Ammon. bromidi, § i. 
Tr. cannabis ind., 3 vi, 
Mucilag. acaciae, § iv, 
Ess. menth. pip., 3 ii. 

M. Sig. — One teaspoonful thrice daily in water. 

The bromide of ammonium seems to exercise a 
special influence on the uterine functions, and in cases 
of disturbed sympathetic regulation and ovarian pain, 



- 36 - 

which are common accompaniments, the relief af- 
forded by the above combination is very considerable. 
Sometimes it is admirable to combine the canna- 
bis indica with a hyperemiant. I have found the fol- 
lowing useful: 

^ Ext. cannabis indica^, gr. vi, 
Ferri ammon. citras, gr. xlviii. 
Ft massae et divid in pillulae No. xxiv. 
M. Sig. — One thrice daily. 

It is of the greatest importance that the disturb- 
ance that leads to the uterine hemorrhage should be 
found and remedied. In cases of simple relaxation, 
when there is no organic difficulty, the use of gallic 
acid, or hot syringing has done good in many cases. 
In some of my patients a lacerated cervix, intra-uter- 
ine polypi, or fibrous tumors have been at the root of 
their anaemic headaches. 

I have lately seen a number of cases of anaemic 
headache where the cause was found to be the loss of 
blood from some unsuspected source. Two or three 
of these had hemorrhages from the rectum as the re- 
sult of hemorrhoids; one had attacks of expistaxis; 
and I discovered the cause of an almost constant 
headache in a person who had lived in the tropics, to 
be haematuria which was the result of malarial dis- 
turbances and filaria. A lady sent to me by Dr. D. 
Bryson Delavan, of this city, had vertical anaemic 
headaches of great severity, and bodily exhaustion 
which was at times alarming, and in this case 



— 37 — 

there existed haemophilia. Bleeding from the gums, 
nose, dysenteric fluxes and menorrhagia, or rather 
metrorrhagia were the causes of the drain. It is always 
well in these cases to inquire as to the existence of 
such possible troubles and remove them by appropri- 
ate means. In the case of hemorrhoids of course 
there is nothing effective but surgical procedures. In 
the other cases our reliance must be upon astringent 
remedies and haemiants. Gallic acid alone, or with 
the acetate of lead, astringent injections of various 
kinds, and iron or arsenic are to be made use of. 
Those who have described or seen much of such dis- 
eases as progressive pernicious anaemia, or other con- 
ditions in which the red corpuscles disappear, find that 
arsenic is often superior to iron — a conclusion with 
which I am inclined to agree. Such idiopathic dis- 
orders as those of which I speak are undoubtedly 
neurotic, and the value of arsenic is a matter of easy, 
practical determination. When iron does good in such 
cases I have found the alkaline or neutral preparations 
better borne and assimilated than the others. The 
older French writers placed great reliance upon the 
carbonate, the peroxide and the mild salts generally, 
and the Germans have given us the malate, which is 
an easily digested and excellent preparation. The 
albuminate,* or peptonate, may be selected when there 

* In the N. Y. Medical Record, Aug. 28, 1884, I first 
called attention to the value of the albuminate of iron in 
anaemic and hysterical women, and those with idiosyncrasies 



-3«- 
is much of the gastric feebleness which is pronounced 
in so many bloodless women. I have combined the 
albuminate of iron with the carbonate of soda in small 
quantities. We must not lose sight of the fact that the 
use of soda in large amounts, or of Vichy water, is 
quite apt to hamper our efforts at cure by blood im- 
poverishment, and other alkaline mineral waters should 
be forbidden as well. 

With manganese as a substitute for iron, I have 
had little or no experience, and such as I. have had 
is not encouraging. 

During the past few months I have found that 
the appropriation and conversion of iron in the sys- 
tem is helped by the conjoint administration of some 
substance rich in oxygen. Oxygen gas itself has been 

who often declare their unwillingness or inability to continue 
the iron even in most minute doses. 

In 1871 Diehl announced the discovery of the albuminate 
of iron, which after all is not a true salt. 

Miahle has held that "the albuminate of the peroxide of 
iron is formed in the blood, and that this is the basis of the 
red globules," and it has been shown that the presence of an 
alkali favors the catalytic change. Some iron salts are abso- 
lutely inert as remedies, and pass unaltered from the body. 
Among these are the ferro and ferricyanides of potassium, and 
other double salts which are not precipitated by the alkalies. 
The combination of iron and albumen with an alkali seems to 
be at once a measnre likely to be of. value from a therapeutic 
point of view, and so I have found it. The preparation I use 
is in lozenge form, each containing about twelve grains of the 
albuminate of iron. 



— 39 — 

used for this purpose for several years by many French 
therapeutists and by Dr. A. H. Smith and others in 
this country, and I have used nitrous oxide gas. If 
the permanganate of potassium be given alternately 
with any soluble preparation of iron it will immeasur- 
ably increase the good effects of the latter, and if the 
former be made up with coca butter it will produce no 
gastric irritability or intolerance. Five grains of the 
albuminate or ten grains of the sub- carbonate may be 
taken after eating, and one-half to one grain of the 
permanganate in a tablet before eating. 

Fothergill advises the combination of arsenic r 
sulphate of iron, nepaul pepper, and the pills of aloes 
and myrrh. 

In the headaches due to imperfect cerebral cir- 
culation and heart weakness, I place much reliance 
upon strychnia and drugs of its class. The following 
is an excellent tonic: 

1$ Stiych. sulph... gr. ss. 

Ferri et quin. citras, 3ivss. 

Digitalis pulv., gr. xxiv. 

Ext. hyoscyamiae, gr. xlviii. 
M. Ft. massae et divid. in pill, no. xlviii. Sig. — One 
after each meal, to be increased. 

Digitaline which has been recommended by many, 
is, I am convinced, a dangerous and unreliable 
remedy, and occasionally produces collapse, or ob- 
stinate vomiting. I prefer the older preparations 
provided they be fresh. In cases of chronic cerebral 



— 40 — 

anaemia with lowered arterial tension I have used 
-strophanthus, which is safe and not cumulative. In 
some recent cases I have obtained aid from the fol- 
lowing: 

1$ Bruciae, gr. i. 

Tr. ferri chlor., 3 vi. 

Tnfus. digitalis, § iv. 
M. Sig. — One teaspoonful in water after each meal. 

When the anaemic headaches are attended by varied 
symptoms of general nervousness, and fall under the 
head of " neurasthenic," we find much benefit from 
the phosphates and hypophosphites. Day recommends 
the combination of the hypophosphite of soda with a 
"bitter tonic. In combination with one of the cinchona 
-series, provided the dose of the latter be not too large 
it is excellent. Quinia though physiologically indi- 
cated, often aggravates an anaemic headache when ad- 
ministered in unsuitable quantities. The anaemic brain 
is irritable, and as I have before said is liable to 
hyperemias of rapid development. 

A congestion is likely to occur from a dose of 
quinine that in the ordinary individual would scarcely 
Jbe appreciated, and the anaemic headache may be re- 
placed by another of a different type. I therefore 
make use of very small doses of the sulphate of qui- 
nine or cinchona, or sometimes prescribe Huxhams' 
tincture. Some of us wonder why many of the pro- 
prietary combinations of iron, quinine and strychnia 
-either do no good, or else aggravate the patient's 



— 41 — 

sufferings, but it is not surprising that an arbitrary pro- 
portion of component parts will not suit every case. 
The physician should use his own judgment more 
often than he does in dosage. "Ready mixed " medi- 
cines are apt to be convenient to the busy man, but 
unreliable. 

In cases of anaemic headache with depression, the 
administration of opium in combination with iron and 
phosphorus, is likely to do good, but on no ac- 
count should the patient be told what remedy is given 
him. 

]$ Phosphori, gr. i, 

Opii pulv., gr. xx, 

Ext. belladonnse, gr. v, 

Ferri redacti, 3iv. 

Ft massse et divid in pillulae No. xl. 
M. Sig. — One morning and night. 

For the relief of the same complication we may 
order cocaine in combination with dilute phosphoric 
acid and quinine. 

5 Cocaini hydrochloratis, gr. vi to viii, 
Quininae sulph., 3 i, 
Tr. ferri chlor., 3 v, 
Acidi phosphorici dil., § i, 
Syr. aurantii flor., | iv\ 

M. Sig. — One teaspoonful thrice daily in water. 

When there is constipation, a state very common 
in cerebral anaemia, and attendant mental depression; 
it is important to clear the lower bowel, and aloes 
or its derivative aloin is indicated. 



— 42 — 

The following will do for occasional use: 

1$ Strych. sulph., gr. i, 

Ext. belladonnae, gr. viii, 
Aloin, gr. xii, 
Ext. fel. bovis 3 Hi. 

Divid in capsulae, No. lx. 

M. Sig. — One or two every other night or when needed. 

Saline purgatives are not suited to anaemic pa- 
tients, nor are alteratives such as iodine or its com- 
pounds, with the exception of the iodide of iron. 

In cases where there is much insomnia and de- 
pression, opium may be given with some mixed cathar- 
tic, and Day's formula is a good one: 

5 Ext. opii 

Pulv. rhei, aa gr. i, 

Pil colocynth co., gr. iss. 

M, Sig. — At a dose at night. 

I have found paraldehyde to be well borne and 
free from disagreeable after-effects. It is best given 
in capsules and each soluble capsule should contain 
ten minims, ttq 30 — tf# 60, repeated if necessary, will 
usually secure sleep. It does not seem to have any 
analgesic effect.* 

The elixir of absinthe is an excellent menstruum 
in the tonic prescription. I have used it as well as the 



* In large doses it is sometimes excreted in great part by 
the axillary sweat glands and, as the odor is far from sweet, 
the result is often embarrassing to the patieni. 



— 43 — 
elixir chartreuse, and am sure it has helped many 
anaemic women, with headache due to depleted brains, 
and both are of service when there is an antipathy 
which is often purely notional, against wine. 

5 Ferri. iodidi., gr. xxxii. 

Tr. stramonii, 3 iii- 

Elixir absinthii., § ii. . 

Syrups simplicis, ad. 3 iv. 
M. 

Sig. — One to two teaspoonsful in water after meals. 

^ Ferri. et potass, tartras., 3 vi. 

Aquae bull., q. s. to dissolve. 

Tr. belladonnas, 3 iiss. 

Elixir chartreuse viridi., ad § xii, 
Sig. — One to two teaspoonsful every four hours in water. 

5 Ferri. et cinchonidiae citras., Biss. 

Fl. Ext. gossypii. radicii. corticis., § i. 

Elixir chartreuse viridi., § iv. 

Aquae anisi., § viii. 
M. 

Sig. — One to two teaspoonsful in water every four hours. 

The above is of benefit when the anaemic head- 
aches are due to some uterine drain and relaxed 
muscular fibre. 

Diseases or defects in the apparatus of respiration 
and which interfere with the proper oxygenation of the 
blood are quite apt to induce anaemia and chlorosis, 
which may lie at the foundation of headaches of a 
constant and distressing nature. Any obstruction of 
the upper air passages is prone to interfere with the 



— 44 — 

free admission of air to the lungs; and this difficulty- 
may consist in the enlargement of the tonsils, or de- 
pend upon various diseases of the nasal fossa. Hy- 
pertrophied turbinated bones and polypi have been 
found by Curtis and others to account for persist- 
ent headaches among their patients, and the use of the 
nasal trephine has worked wonders in cases that have 
resisted drugs. I have myself cured many headaches 
by the removal or reduction of enlarged tonsils in 
children, and in two cases epileptic paroxysms have 
ceased to recur after this operation. If the patient is 
disinclined to permit surgical measures, it will be 
found that the careful application of chromic acid will 
cause a cicatricial reduction of the glands. 

In some asthmatic individuals or sufferers from 
chronic capillary bronchitis or emphysema, such head- 
aches are by no means an uncommon result of defect- 
ive oxygenation. Belladonna or its alkaloid may be 
made use of with confidence, for they act well in most 
cases. 

Aged people of spare build and gouty habit are 
apt to suffer from anaemic headaches, the explanation 
of which is probably gouty spasm of the vessels, and a 
limited anaemia. The headaches are often accom- 
panied by insomnia, and by weakened digestion. In 
such cases much can be done with the diffusible 
stimulants, and Hoffman's anodyne agrees well when 
given alone, or with ammonia. The moderate use of 
alcohol by such patients is in every way advantageous, 



— 45 — 
and I prefer for them either a good rye or Scotch 
whiskey taken at meals, or a very dry champagne. 
Horseback or tricycle exercise is to be counselled, es- 
pecially when the person is performing intellectual 
labor. Many such persons live upon farinaceous, and 
so-called health foods of a cereal nature, which under 
the circumstances are about as injurious as can be 
imagined. Oatmeal is no exception and its use should 
be forbidden. Fats are also bad. 

The general treatment of these persons should be 
supporting. Phosphorous is contraindicated but not 
arsenic. The use of soda in combination with the 
bitter tonics is apt to do good in improving the weak 
digestion that usually accompanies the condition and 
the old formula so familiar to most practitioners of the 
bicarbonate of soda and tincture of gentian, and the 
syrup of rhubarb with perhaps a few grains of the car- 
bonate of ammonia will often prove to be of great 
services. 

There is an alarming form of headaches which 
anaemic children sometimes present, and the appre- 
hension consists in the fact that it is symptomatic of a 
grave disorder which is ultimatively fatal. I allude to 
the formation of the hydrencephaloid condition of 
Marshall Hall; or the deposition of adventitious sub- 
stance in the brain. Distention of the perivascular 
spaces characterizes one of these, and the pressure of 
a tuberculous mass may produce anaemia, both of 
which result in severe and constant headache. If 



- 46 - 

vomiting be present- with such head pain, and the 
child becomes listleness and stupid, a very grave out- 
look may be taken. Decided and prompt alterative 
measures are imperative. Cod-liver oil, phosphorous, 
feeding, and possibly the iodide of potassium with bel- 
ladonna are indicated, and if the child be at school it 
should promptly be removed and sent into the country. 

Sinkler * has called attention to the occurrence of 
migraine which he believes is more common among 
children than is generally suppposed. His conclusion 
that it may begin at the eighth or ninth year, must be 
accepted by those who see much of children's head- 
aches. He goes further by stating that the form of 
the disease being thus early, is apt to disappear at full 
development (i. e. adult life). I cannot agree with 
him in this so far as girls are concerned. 

Sinkler insists upon the use of fatty food — cod- 
liver oil, cream or butter — the exhibition of bromide 
in small quantities, the correction of possibly existing 
ocular defects, and " in all cases of migraine we should 
look carefully into the condition of the teeth, and 
have unsound ones filled or removed." 

Two new remedies have been suggested for the 
cure of headaches — antipyrine and acetanilid, or anti- 
febrine. 

In January, 1887, Ungar related his experience 
with antipyrine in the treatment of hemicrania, and in 



* Medical News, Oct. 29, 1887. 



— 47 — 

March Dr. C. B. Lyman, who had been induced to 
try the remedy after the publication of Ungar's suc- 
cess, administered it in several cases of neuralgia of 
the cervical, facial, and supra-orbital or mixed varie- 
ties, with more or less benefit. The first of these 
observers experimented with it as a successor to the 
salicylates, which had proved to be of great value in 
his hands in several varieties of headache, and he wit- 
nessed no evil results from doses of even 23 grains. 
Lyman used an initial dose of 15 grains, repeated 
two or three times if necessary, and relieved the par- 
oxysms, but did not prevent their recurrence. In 
March last* I began a trial of this drug, and after- 
ward its successor, antifebrine, in a variety of head- 
aches, in insomnia, and in epilepsy. Some of these 
cases had been treated with more or less success with 
the salicylate of sodium, and the usual remedies, and 
the cases of epilepsy were under modified bromide or 
other treatment. The cases of headache selected were 
those of migraine of the angeio-spastic and angeio- 
paretic varieties, as well as ordinary facial or sub- 
occipital neuralgias; and the cases of epilepsy which 
were chosen were those of the symptomatic form com- 
plicated with objective and subjective indications of 
cerebral disease, as well as the simpler forms which 
seemed to be dependent upon continued states of 
cerebral ischaemia, cerebral instability, etc. 

In angeio-spastic migraine with evidences of 

N. Y. Med. Jour., May 28, 1887. 



- 4 8 - 

cutaneous anaemia, dilated pupils, and coldness, the 
headache commencing in the morning, I found that 
both antipyrine and antifebrine would quickly abort 
the paroxysms after the first dose. 

Miss. T. had taken salicylate of sodium in doses 
of gr. xxx repeated once or twice, with variable relief. 
Cannabis indica and the chloride of ammonium failed 
to do good. Her headaches were connected with sex- 
ual irritation and excitement. She was very anaemic 
and hysterical. One powder of fifteen grains of anti- 
pyrine relieved the pain in less than an hour. The 
repetition of a daily dose in the morning completely 
suspended the headaches for a period of two weeks 
during which the patient was under observation. She 
was put upon a course of iron, which she took mean- 
while. 

Mrs. R. suffered from vague headaches, a sense 
of vertical pressure, and general anaemia which was 
largely due to frequent uterine hemorrhages. After 
the catamenia, and during the first half of the month 
she had attacks of angeio-spastic migraine. Five 
grains of antifebrine produced tinnitus, but relieved 
the headache. This patient subsequently obtained 
slight relief from cannabis indica. 

I have used these drugs in a large number of cases 
and have given as much as 45 grains of the antipyrine 
in two hours, a comparatively short space of time. 
Antifebrine is the safest, and though one case is 
reported where large quantities produced a variety 



— 49 — 

of disagreeable symptoms, I can only say from my 
own experience that I have never seen anything but 
temporary unpleasant consequences. Antipyrin may 
be administered hypodermically in doses of eight or 
ten grains in an equal quantity of water. See/ who 
has used it, believes it to be superior to morphine, and 
it has none of the disadvantages of the latter. Of the 
local analgesic properties when used in this way I will 
say more when we come to the discussion of neuralgia. 
Dujardin-Beaumetz recommends ethroxy-caffeine, 
a new drug, but it should be used with the greatest 
caution for it is dangerous and unreliable. 

§ Ethroxycaffeine, gr. xii, 
Sodii salicylat, gr. xv, 
Aquae destill., 3 iiss, 
Sig. — From five to ten teaspoonsful as indicated. 

Of other comparatiuely untried new preparations 
of this series, I will not speak. 

Iodoform is an excellent remedy in some cases of 
intractable anaemic headache in strumous subjects and 
may be given in repeated doses alone, or with iron. 

The citrate of caffeine is of value in anaemic 
headaches, but should be given in much larger 
doses than are generally prescribed — it rarely has 
much effect in less than five grain doses. Various 
effervescing salts such as the " bromo-caffeine " or 
the effervescing citrate of caffeine taken when the 



1 Les Nouveaux Remedes, Dec. 8, 1886. 

5 * 



— . 5 o — 

headache first appears will often arrest it. I have 
obtained good results from a distillate of coffee 
made by Mr. Angelo, of this city, at my suggestion, 
and use it in half dram and dram doses, well diluted. 

I have lately used salol — another coal tar pro- 
duct — in several cases with good effect. The dose is 
five grains, to be repeated. Antipyrine is quite sol- 
uble in water, but antifebrine sparingly so. 

Germain S£e recommends that these drugs be 
given in ice water which counteracts their depress- 
ing effects on the digestive organs. 

Betol or naphthalol, which was introduced by 
Neushe of Bern, is useful not only in anaemic head- 
aches but those of a neuralgic character. 

Moxon recommends morphine in headaches with 
extreme prostration and sickness, when the extremi- 
ties are cold and the pulse is feeble and the patient 
has been days without getting relief. In such cases 
one-sixth grain of morphine with the addition of -fa 
grain of atropine are injected hypodermically at reg- 
ular intervals. 

Some years ago, at the suggestion of Dr. John E. 
Blake, I administered nitrous oxide to anaemic patients 
as an hypnotic, and incidentally found that its value 
was very great when anaemic headaches existed. The 
ordinary apparatus used by dentists was that tried, 
and I turned the valve so that air was admitted in 
varying proportions. I have within the past ten years 
used the nitrous oxide treatment in hundreds of 



— 5i — 

cases — many being those in which headache was a 
feature. My conclusions as I have elsewhere said 
are that not only is the assimilation of iron very much 
increased when gas is administered but the in- 
tegrity of the cerebral capillaries is brought to a 
much higher standard. The clinical results are the 
improvement in sleep, a gain in weight and color; and 
the subsidence of headache. The gas should not be 
given to the point of insensibility — or great vertigo — 
but as soon as any tingling of the lips or tongue 
is produced, its use should be discontinued for a few 
minutes. Four gallons of mixed gas and air should 
be given daily. 

Certain drugs which rapidly congest the cerebral 
blood vessels are of service. Among these as im- 
mediate remedial agents I may mention nitrite of 
amyl (which by the way is not an entirely safe remedy), 
and trinitrine or nitro-glycerin. The first named may 
be used at the commencement of an attack, or inhaled 
in small quantities several times daily. The latter 
may be given in tablet form or in liquid combination 
with iron. 

The patient should be made to seek a recumbent 
posture so that the head shall be to some degree 
lower than the rest of the body, and he should lie in this 
way several hours daily. 

The diet of all patients with headache of anaemic 
origin should be of the most nutritious kind and 
largely nitrogenous. As the digestion is weak the 



— 52 — 

food should be selected with great care, and given 
frequently. Milk peptonized or skimmed, the beef 
peptonoids. Koumyss (that with the true Russian 
ferment the Cranmoor being the best), or Matzoon 
which are easily digested milk preparations; butter-milk 
which is serviceable in the gouty cases; eggs, beef juice 
or raw meat should form the staple diet, while articles 
which simply satisfy hunger or stimulate the appetite 
should be given only when the patient has recovered 
his power of assimilation. The good effects of con- 
densed food are most conspicuous when enforced rest 
is obtained. The so-called "rest treatment," is often 
a misnomer. It may be so purely an arbitrary and 
ill-suited therapeutical measure as to do more harm 
than good. Not only is the patient's bad physical 
condition aggravated, but many a woman is made 
hypochondriacal or worse. The term has covered a 
multitude of blunders. Like everything extreme, it is 
powerful for good or evil, and should never be re- 
sorted to, except with a due consideration of the pa- 
tient's exact state, and what is to be accomplished. 
It does not do to put any or every woman to bed, as 
has been the fashon of past years, for no two cases 
can be managed in exactly the same way, and one 
woman will grow nervous and more miserable under 
the compulsory " rest " that may cure another. The 
real end in view should be the prescription of rest 
that will prevent the expenditure of nervous force in 
muscular movements, from exceeding the production 



— 53 — 
of energy and food assimilation. Nothing more or 
less. This means watchfulness and care, a good 
nurse, sometimes removal from home when the patient 
is unreasonable, hysterical or fanciful; regularity in 
eating, passive movements and massage when needed, 
skin stimulation by spongings of dilute alcohol; or 
faradization when the woman tires easily. One of the 
greatest benefits of massage is the exercise it affords, 
without the use of volition, and when the effort of 
volition is tiresome, the tone of the muscle is im- 
proved by the exercise effected by another. 

General faradization by means of broad sponge- 
covered electrodes, and mild currents passed generally 
over the body are beneficial. In persons with weak 
digestion, galvanization of the sympathetic is advan-» 
tageous. 

In many cases anaemic headaches are connected 
with gastric derangements which need treatmeut. 
Bismuth, the bitter tonics — calumbo being the easiest 
of digestion — quassia and the peptonoids should be 
used as occasion requires. The capacity of some 
women to make blood is so poor that nothing can be 
done for their headaches until their digestive power 
and assimilation are strengthened, and it does little 
good to give iron or specific drugs while no gain is 
being made in other directions. 

In very extreme cases — the method of rectal injec- 
tions of fresh blood — dried blood, or beef juice made 
in suppositories with gelatin may be necessary. These 



— 54 — 

headaches often exist in women who have hysterical 
vomiting, when besides moral treatment some such 
means as those just suggested are in order. 

The mineral springs, which best suit the subjects 
of chronic anaemic headaches, are of course those of 
a chalybeate nature. The Rockbridge alum and 
Sweet Springs of Virginia, Columbian Spring of Sara- 
toga and Sharon are all within reach in this country; 
and those at Bournemouth, Tunbridge and Hast- 
ings Wells of England, Spa of Belgium, St. Moritz, 
Switzerland, Schwalbach, Pyrmont, Alexis-Brunnen 
are the best known in Europe. 

Most of the foreign and domestic iron waters as 
well as the arsenuiretted waters are bottled and may 
be had without trouble. 



CHAPTER III. 

ORGANIC HEADACHES. 

Nothnagel,* one of the most practical of all Ger- 
man writers, is not disposed to attach much import- 
ance to the significance of headache as a diagnostic 
sign in organic brain disease; he even goes so far as 
to say that in chronic cerebral anaemia he doubts if 
headache is actually due to the chlorosis (sic.) or the 
anaemia itself, for -the intense and pernicious anaemia 
which is produced by carcinoma is rarely expressed by 
headache. It cannot be denied, however, that the 
constant existence of localized pain, or of pain asso- 
ciated with other symptoms, is suggestive of mischief 
within the cranium, which is more or less grave, and 
is to be taken out of the category of functional dis- 
orders. The location of a constant pain often points 
to cerebral abscess, and this is especially true when 
this lesion is a result of aural disease. 

The most familiar form of headache of the kind 
of which I speak, is that associated with syphilis in 
some of its stages. When we find a nocturnal head- 
ache of very great intensity, it is usually of specific 
origin. 

" There is no description of headache," writes 
Dowse, " and one might say, no kind of pain, which 



*Wiener Med. Presse, No. 13, 1879, 



- 56 - 

equals in intensity that which results from a localized 
hyperplasia of the dura mater."* 

It is sometimes almost unbearable, and varies in 
character. In cases where the bones of the skull are 
involved it is diffused, and affects the entire scalp, is 
deep and increased by contact, and in this respect some- 
what resembles rheumatismal headache. The head- 
aches of syphilis are also of a localized character, and 
may in this respect resemble clavus. In old cases the 
pain seems to disappear when the cerebral mass is in- 
vaded, and the dura is not subjecte^d to so much pres- 
sure as in the beginning. It is not usually connected 
with tibial pain. When it is a feature of syphilitic 
epilepsy it, as a rule, precedes the paroxysm. In the 
early stages of the disease it may be of a light char- 
acter and both nocturnal and diurnal. Some authors 
speak of a headache of a low grade with paroxysms of 
great severity, and exacerbations which occur every few 
weeks as the result of depressing causes. Dowse de- 
scribes this form very graphically: " The pain is of a 
different kind to that of the other forms of headache; 
it is of a dull heavy aching character. It has no 
central point from which it radiates. It is usually dif- 
fused more or less over the whole of the forehead, 
and gives to the patient a hang-dog look; often the 
complaint is that the eyelids cannot be raised, they 
feel so heavy; the whole of the vessels of one eyeball 

*Syphilis of the Brain and Spinal Cord, Part i, p. 24. 
London, 1879. 



— 57 — 

may be congested and not the other, or both may be 
similarly affected." Temporary ptosis, squinting di- 
plopia, vomiting, tinnitus, somnolence, slow speech, 
monoplegias, and a variety of greater or less troubles 
suggest syphilis. I have always been suspicious of 
headaches with attendant stuporous symptoms or 
vertigo. 

Our therapeutical indications are simple, and one 
can hardly go wrong, for the list of efficient drugs is 
so small. My reliance is upon the iodide of potassium, 
but in large doses* * I have cases under treatment at 
present who are taking one hundred and twenty grains 
thrice daily, or more than half an ounce in the twenty- 
four hours, and this quantity alone keeps the disease 
in check and the headaches absent. In most cases.it 
is safe to begin with. ten grains, three times daily, in 
water. A saturated solution is better dispensed than 
any other, and more convenient, and the daily dose 
can be at first increased one drop, then two, then five, 
until the point of tolerance is reached. It does no 
good to give large doses, when coryza is produced 
and saturation indicated, but the patient should be 
kept on the border line. The iodide is best given in 
alkaline solution, and I prefer Vichy water as a 
vehicle. If this plan is followed the patient will not be 



* Taylor says: "A fraction of a grain of corrosive sub- 
limate, or three to five grains of the potassium iodide, admin- 
istered three times a day, will do no more good than would the 
water in which they are dissolved." P. 663. 



- 58 - 

annoyed by the unpleasant metallic taste or gastric 
derangement. In persons who cannot tolerate iodide 
this way, I have followed the advice of my friend, Dr. 
Keyes, and administered it in milk. In some cases 
mixed treatment may be employed after a course of 
the iodide. 

A pill of great service in anaemic cases of cerebral 
syphilis is the following: 

5 Pill hydrarg. massae, 

Ferri sulph. excissicat., 

Ext. hyoscyamias, aa gr. xlviii. 
M. Ft. massae it divide in pillulae No. xxiv. 
Sig. One thrice daily. 

This combination is especially good in the early 
headache of the disorder. 

In these cases, and those more advanced, we may 
hasten improvement by inunctions, either of the old- 
fashioned blue ointment, or of the 20-per-cent. oleate 
of mercury; mercurial baths are sometimes excellent. 
Both ergot and opium give the patient much relief, 
and particularly the latter. I have lately use anti- 
pyrine and antifebrine with good effect. Much com- 
fort is derived in these and other headaches from the 
use of cold applications to the head, and a convenient 
and cleanly apparatus is the head-coil, made of India 
rubber pipe. One end is attached to a vessel filled 
with ice water, the other hangs over the side of the 
bed and discharges into a suitable vessel. An effectual 
method of cooling the head was devised by Hughes, 



— 59 — 

of St. Louis, who applies sulphuric ether to the scalp. 
For immediate use there is nothing better than the ice 
bag filled with ice and salt, and changed from time to 
time. 

The headache of meningitis either pachy, or 
lepto, is, as a rule, diffused and very intense. That 
of the first named is ordinarily chronic, may be of 
traumatic origin and is dull and connected with suffu- 
sion of the face, redness of the conjunctivae, and is 
accompanied by some of the symptoms of cerebral 
congestion. The characteristic pulse which was de- 
scribed by Nothnagel is sometimes irregular, and 
when there is irritation of the pneumo-gastric nerve 
in basilar cases there is periodical acceleration. Con- 
fusion of ideas, mental weakness and feebleness of 
memory are often present, and when there is a men- 
ingo-encephalitis we are quite apt to have cortical 
sclerosis, delusions of grandeur and dementia. The 
headache in chronic cases is always present, but just 
as in the form of syphilis just mentioned, there may 
be painful exacerbations of an acute character, which 
are neither confined to day or night, but are precipi- 
tated by exposure to the sun or by excitement. 

Belladonna, ergot and opium are the three 
remedies which promise most in the way of relief, and 
these should be used energetically. The first may be 
give to the toxic point, and the second in doses as 
large as can be borne by the stomach. Less than one- 
half dram of the fluid extract thrice daily does little 



— 60 — 

or no good. The belladonna in combination with the 
potassium iodide is an excellent form of continuous 
treatment. Small doses of the bichloride of mercury 
act nicely sometimes even when there is no suspicious 
of specific disease. In cases of rheumatismal origin 
the salicylate of soda in good full doses repeated fre- 
quently in alternation with the acetum opii will often 
lull the pain. Aconite and gelsemium are recommend- 
ed. The latter is spoken of very highly by Bartholow, 
especially when there is a febrile state, where he rec- 
ommends TT£v. doses of the fluid extract repeated every 
two hours, so as to maintain a uniform physiological 
effect. The extreme method advised by the Germans, 
which consists in shaving the hair and painting the 
scalp with croton oil, is not believed to do much good, 
nor is extensive cauterization or blistering. 

Cerebral tumor is a fruitful cause of organic 
headache, and in an excellent article in Pepper's 
System, the statistics collected by the writer show that 
of roo cases of cerebral tumor 66 patients complained 
of headache, which was described as " torturing," 
or agonizing in twenty instances. 

The headache of cerebral tumor is very intense, 
and has been looked upon by many clinicians as one 
of the chief indications and before the days of absolute 
(?) localization -as of pathognomonic importance. The 
pain always bears more or less relation with the situation 
of the growth. With tumors of the convexity it is situ- 
ated anteriorly or posteriorly or laterally, when we may 



— 61 — 

find motorial or sensorial symptoms upon the other 
side of the body. In one case alluded to by Rosen- 
thal " the headache was accompanied by painful sen- 
sations and formications in the right arm; these symp- 
toms disappeared after a time and were replaced by 
an anaesthesia of the limb. At the autopsy, a tuber- 
culous tumor of the size of a walnut was found upon 
the convexity of the left cerebral hemisphere; the 
pathological changes extended to the deeper portions 
of the brain, lesions of which are accompanied by an- 
aesthesia of the limbs." Of five cases of gliomatous 
tumor three complained of no pain whatever. These 
authors find that cerebellar tumors were not necessarily 
associated with occipital pain. 

A headache of intense character with mono- 
plegias or more extended losses of power, convulsions 
or vomiting, is always suggestive of an adventitious 
deposit; and if the symptoms are irregular, the patient 
having great pain which subsides after a compara- 
tively long siege and return again with a new acces- 
sion of motorial or sensorial symptoms, the diagnosis 
is strengthened. This temporary disturbance may be 
and often is suggestive of an accomodation of the 
brain to the pressure. 

Organic cerebral headaches are as a rule pre- 
ceded by symptoms of greater or less significance and 
are not of sudden onset. Such headaches as a rule 
are intractable and puzzling. Headaches due to tu- 
mors are often mistaken for those of a functional 



— 62 — 

nature, the existence of the growth being unsuspected. 
I can recall two cases where a profound central anae- 
mia with headaches of a commonplace type existed 
for a long time, and only after death were large central 
growths found. Happily the ophthalmoscope will 
usually reveal the existence of neuritis and choked 
disk. The symptom of a suspected central change 
may turn out after all to be the manifestations of a 
general condition and Wood relates a case of head- 
ache of this nature in his excellent work. 

The patient was a man who suffered for years 
from agonizing headaches of daily occurrence. In 
time the headaches became associated with petit mal- 
and Wood made the diagnosis of organic disease of 
the brain. At last the small joint and some of the 
larger ones were attacked simultaneously with a furious 
sudden and general gout, with deposits, etc., etc., 
when the headaches were relieved to some extent. 
The patient was entirely crippled but had his headaches 
only occasionally. Wood was led to believe that this 
was 'originally a gouty thickening of the dura mater 
with deposit. 

Percussion of the skull is a useful diagnostic 
means in determining the location of a tumor at the 
convexity, but care should be taken not to confuse 
scalp tenderness with that of a more subtle nature. 

The therapeutical indications are varied. In the 
case of tumor we are to diminish the pressure caused 
by the presence of the growth, and lessen its irritant 



— 6 3 - 

effects. One of the peremptory hygienic measures 
which is applicable in this form of organic trouble as 
well as others, is the abstinence from anything that 
may increase the cerebral blood supply. Mental labor, 
alcoholic indulgence, heated rooms, and over-eating, 
are all apt to aggravate the pain. The hair should be 
kept cropped short and the head gear should be light 
and well ventilated. Tight collars should be dis- 
carded. The use of cups to the back of the neck, oc- 
casional bleeding, such as has been recommended by 
Dr. Glasgow, and leeching the nostrils, or scarification 
will afford the patient relief. Of course cold applica- 
tions are in order. 

So far as medicines are concerned one may em- 
pirically use the potassium or ammonium iodide, both 
in large doses. Hypodermic injections of morphine 
atropia or antipyrine are to be resorted to when the 
pain is intense, and the mixed bromides are useful. 
The combination of the iodide and bromides is a good 
one in nearly all forms of grave cerebral disease: 

$ Potass, iodide, 3 v. 
Sodii bromidi, § iss. 
Potass carbonas, 3 iij - 
Tr. columbo, § viij. 

M. Sig. One teaspoonful thrice daily. 

Galvanism and faradism should be given a trial 
and the former especially will often relieve an organic 
headache, though of course only temporarily. 



- 6 4 — 

Now that cerebral localization has been of such 
great aid to the surgeon, and " brain surgery " has be- 
come a measure which is not necessarily a very dan- 
gerous one so far as operations that do not result in 
opening the dura mater are concerned, it seems as if re- 
lief might be afforded more often than it is; especially 
when evidence of cortical pressure are concerned; and 
when there is evident tension of the most tolerant of 
the meninges. 



CHAPTER IV. 

TOXEMIC HEADACHES. 

Under this head may be included the form of 
head pains which are due to the retention in the blood 
of various substances which may be the production of 
disease, or the result of administration, unconscious or 
otherwise. Among the first I may mention lithaemic 
headaches, uraemic headaches, the headaches of fever, 
of drugs, of tea and coffee and tobacco, and of metal- 
lic poisoning. Though pathologically some of these 
might better be described under the head of congestive 
or anaemic headache, I think their clinical character- 
istics prominent enough to entitle them to separate 
description. 

An experience of many years has taught me that 
lithaemic poisoning is at the bottom of many functional 
nervous diseases, as well as some organic ones. Its 
effects are shown in a multitude of perversions of 
sensibility, and even motility, and the importance of 
toxaemia due to retained nitrogenous substances is 
too often unrecognized or disregarded. 

Many individuals of the gouty habit, without 
actual classical gout, but with a thousand and one 
erratic symptoms, are the subjects of headaches which 
readily disappear when a proper alteration of habits 
and food is made and when they are placed upon 
remedies of a suitable nature. The subjects of such 

6 R 



— 66 — 

headaches are often men, and more usually those past 
middle life, though the headache of lithsemia is con- 
fined to no particular age. The victims are usually of 
sedentary habits, whose powers of excretion are im- 
paired, and who meanwhile live upon articles of food 
which are improperly assimilated. Editors, literary 
men generally, lawyers, doctors, clergymen, clerks and 
others who are compelled to spend long hours indoors, 
and who rarely use their voluntary muscles are quite 
subject to attacks of head pain, and such states mark 
the accumulation of uric acid. The" urine is loaded 
with the familiar brick-dust sediment; it is scant, and 
often is passed frequently, and they have an annoying 
tickling or burning sensation in the urethra. The 
bowels are constipated, digestion is slow and poor and 
there is flatulence. Sleep is broken and bad, and dis- 
turbed by dreams and eructations of wind. The patient 
is depressed, morbid, easily fatigued; has muscular 
soreness, and formication, perhaps, of his finger tips, 
feet, tongue, lips or buccal mucus membrane. Mental 
work or physical exercise is irksome and disagreeable, 
and he has diffused headache and heaviness over the 
orbits. There may be frontal pain, and it may be 
worse on arising, or may take a migrainous type and 
be very sharp and distressing. In some cases there 
may be some alteration or complication of remote 
joint pain of the ordinary gouty type. If the urine 
be examined, it will be found to contain the oxalate 
of lime and the lithates. When the specific gravity of 



- 6 7 - 

the urine is lowered and when the bowels become 
regular, the passages losing their clayey color and 
consistency which belongs to them; there is some 
amelioration of the headache. These headaches are 
often attended by giddiness and tinnitus and by gas- 
tric derangement. 

Haig,* who has devoted much attention to the 
relation of headache to the excretion of uric acid 
conducted a series of observations: " Meat and 
cheese were taken with the object of bringing on a 
headache, for purposes of experiment. The relation 
of this headache to the excretion of uric acid at first 
appeared equivocal, but definite results were obtained 
on separating the urine excreted during the headache 
from that before and after. There appears to be re- 
tention of uric acid before the headache, excessive 
excretion during the headache, and diminished excre- 
tion after the headache. The excess during, balances 
the diminution before and after; there is no absolute 
excess of uric acid; hence the previous equivocal re- 
sults. During a headache there is little or no altera- 
tion of the excretion of urea. The theory which best 
explains everything in this connection is that of di- 
minished alkalescence of the blood. A dose of acid, 
either introduced from without or formed internally, 
may cause temporary retention of uric acid, and so 
lead to headache. Beer will do this. Retention pos- 



* London Lancet, May 28, 1887: also Practitioner. 



— 68 — 

sibly does not explain everything, as the excess during 
headache appears to exceed the previous retention." 

Both Haig and Hutchinson recognize a condition 
which they call " quiet gout," where there are no 
violent symptoms of the real disease. These patients, 
besides presenting the symptoms I have above 
detailed, present as well the indications of hereditary 
influence, and what Hutchinson speaks of as the 
"irritable hyperaesthetic and tired eye." The treat- 
ment of such headaches must consist in the reforma- 
tion of habits, both of eating and drinking, and the 
indulgence in exercise of a proper sort. 

Meat is to be partially, if not altogether, dis- 
pensed with; and cheese and other highly nitrogen- 
ous substances discarded. No wine or beer should be 
allowed, and the green vegetables, fish, oysters and 
poultry are to form the staple diet. 

The exercise provided for the patient should be 
that taken in the open air, but when this is impossible, 
I would suggest the use of Ruebsam's or other rubber 
gymnastic apparatus, the " rowing machine," dumb 
bells, or Indian clubs. An hour in the gymnasium 
has cured the headache of many a hard-worked clerk, 
and tennis, football, baseball, or other good out-door 
sports where there is general muscular exercise, are 
of importance. 

The salicylate of soda, iodide or acetate of 
potash, the preparations of mercury or colchicum are 
useful, and suited to different cases and conditions. 



_ 69 - 

Haig uses the former in small doses, two or three 
grains being given every quarter of an hour for three 
or four doses. I believe that larger doses are of 
greater service, and I rarely give less than ten or 
fifteen grains, and direct the patient to take the salt 
continuously for several days. It should be well 
diluted and always taken when the stomach is not en- 
tirely empty. In some cases it may be combined with 
success with iron when there is anaemia, but there are 
few methods of doing this for the two agents do not 
readily combine. Peabody* has devised the following 
formula which is compatible: 

^ Acidi Salicylici, gr. xx. 

Ferri pyrophosphates, gr. v. 

Sodii phosphatis, gr. j. 

Aquae, § ss. 
M. 

He gives this dose which is a rather large one 
every two hours. It may with propriety be diminished 
in the cases of which I speak. 

Dr. J. Solis Cohen, f of Philadelphia, has fur- 
nished another combination which is perhaps more 
agreeable: 

1$ Sodii salicylates, 3 iv. 
Glycerini, fl § ij. 
Ol. gaultheriae, "filxx. 



*Medical News, Dec. n, 1886. 

fMedical and Surgical Reporter, May 28, 1887. 



— 7o — 

Tr. ferri chloridi, fl 3 iv. 

Acidi citrici, gr. x. 

Liq. ammonii citratis (B. P.), q. s. § iv. 

M. Sig. 3 ij in water three or four times daily. 

When salicylic acid or its compounds produce 
dizziness or gastric distress, the dose should be dimin- 
ished. 

Salol in doses of from five to ten grains acts 
sometimes much better than the salicylates. 

In some cases the headaches will only succumb 
to colchicum which may be administered in combina- 
tion with alkalies: 

5 Vini sem colchici, § ss. 
Potass, acetas, 
Potass, iodidi, 
Tr. cimicifugae rac, aa 3 v. 
Aquae menth. pip., § iv. 

M. Sig. One teaspoonful every four hours. 

Some of the older combinations of colchicum and 
opium are energetic and will often promptly break up 
an attack, for example: 

I£ Ext. colchici acetici, gr. xxiv. 

Ext. opii, aq., gr. vi. 

Ext. colocynth co., gr. xviij. 
M Ft. massse et divid in pill. No xxiv. 

Sig: One or two every four hours when pain is acute. 

The use of small doses of calomel during the con- 
tinuance of the lithaemic state is likely to result not 



— 7i — 

only in an improvement in the function of the liver, 
but correspondingly in the cerebral circulation. 

In headaches due to pure cholsemia, when there 
is much drowsiness, and sometimes a light degree of 
mental aberration, the use of the above pill, or of large 
doses of phosphate of soda will relive the apathetic 
condition of the organ. In this form of cephalalgia 
which is, as a rule, diffused, the mineral acids and 
strychnia are also indicated, and acid baths and gen- 
eral cutaneous frictions are likely to be followed by 
greater elimination of bile. All such patients should 
seek a high altitude and dry climate, and should in- 
dulge freely in exercise of all kinds. 

Ursemic, or rather renal headaches are familiar 
forms of troubles. They are not distinctive so far as 
location is concerned, though many of them are basal 
and posterior, with ocular pain and frontal and vertical 
pressure. The conjoint symptoms of disease of the 
kidneys, urinary and otherwise, makes the diagnosis 
clear, and the head pain is apt to keep pace with or 
be modified by the condition and amount of the urine. 
Attacks of headaches are likely to follow a sudden 
diminution in the amount of urine voided, though this 
is by no means the invariable rule. Vomiting, a ten- 
dency to somnolence, and some alalia are indications 
of a rather desperate state of affairs, and in such cases 
the headache is likely to be followed by coma. The 
constancy of the dull pain, and the presence of con- 
spicuous nervous symptoms, are sometimes likely to 



— 72 — 

suggest the existence of cerebro-spinal meningitis, and 
the prolonged manifestation of, light grades of speech 
and psychical disturbances, with profound sub-occi- 
pital pain tends to lead even the most careful diag- 
nostician into the commission of an error. A case of 
this kind came under my care sometime ago, which 
had been pronounced meningitis by one of the ablest 
clinicians of the city, and I accepted his opinion almost 
without question. The patient's somnolence deepened 
almost into coma and there were suspicious fore- 
bodings of convulsions. Her urine became scant, and 
when examined abundant evidences of waxy kidney 
were found. 

A prompt recourse to hot air baths, diaphoretics 
and remedies directed to favor elimination resulted in 
an immediate lightening up of symptoms and an 
eventual disappearance of the headaches. They 
then returned some time afterwards when the patient 
became careless in her habits, and after two or three 
months of suffering she died. 

Wood speaks of the headaches which may occur 
in the pre-albuminuric stage of gouty kidney when the 
vessels are rigid and the arterial tension raised. This 
headache, however, cannot be said to be fully due to 
retained effete material. It is hardly necessary to re- 
mind my readers that meat should be excluded from 
the bill of fare, and stimulants of all kinds rigidly 
tabooed. A light nutritious, farinaceous and vege- 
table diet, with milk, or a milk diet alone, is that most 



— 73 — 
likely to agree with the patient. Agents which in- 
crease the action of the organs of excretion should be 
vigorously employed. In many cases the uraemic 
poisoning is associated with anaemia of a profound 
type when we may resort to iron — and the old-fash- 
ioned muriated tincture is the best. This may either 
be given with digitalis, or strophanthus; or these 
agents may be tried alone. In some cases the 
use of tri-nitrine is attended with the happiest results, 
and convallarin which is a perfectly safe remedy may 
be prescribed when digitalis is likely to produce gas- 
tric irritability. 

The compound jalap powder at night, or any of 
the purgative mineral waters do good when an exten- 
sive process of renal degeneration has taken place. 

In some cases acetate of potash either in combin- 
ation with digitalis or nux vomica will mildly stimulate 
the kidneys and increase cardiac tonicity. Nux vom- 
ica is I am convinced a better remedy in many cases 
than digitalis and when our desire is to coax the kid- 
neys we may use with propriety. 

5 Tr. nux vomicae, 3 iil, 
Potass acetatis, § i, 
Infus. digitalis, § viii. 
M. — One to two teaspoonsful, every three hours or 
oftener. 

A good reliable pill for many years in use at the 
old New York Hospital is the following, and is es- 
pecially valuable when the disease has led to anasarca. 



— 74 — 

3 Pulv. digitalis 
Kydrarg massae 
Pulv. scillae, aa gr. xlviii. 

M. Sig: — One every night or oftener. 
Ft massae et divid in pillulae No. xlviii. 

These have a mild diaphoretic as well as diuretic 
action. 

Malarial headaches which are so common in 
many parts of this country are really of a congestive 
type. They are not always distinctive and the term is 
too often made use of when a definition must be 
given, and the medical man is not exactly sure of 
what he has to treat. The headache can only be re- 
cognized with certainty when it has a periodical 
character, and disappears with the use of quinine, and 
other anti-periodics. Though the pain may be asso- 
ciated with fever and sweating, the chill being absent, 
it is a rare condition of affairs, and we now often find 
headaches of this kind which are the direct results of 
an impoverished condition of the blood; a sequel 
rather than a part of the malarial attacks. The pain 
is often suboccipital, and when it is periodical, it 
is frontal, very intense, commening in or over 
one eyeball. It is commonly confused with supra 
orbital neuralgia, but is probably a hyperemia of one 
hemisphere, a species of angio-paretic migraine. 
It is attended by great misery and suffering and a 
paroxysm rarely subsides under several hours. Some- 
times it alternates with the chill. Quinine in very 



— 75 — 
large doses, the other salts of cinchona, Warburg's 
tincture or the expissated extract, and arsenic are all 
useful. In many cases the hepatic and gastric de- 
rangement which attends the headaches must be at- 
tended to, and calomel or blue mass in combination 
with capsicum or ipecac in small doses is advised. If 
arsenic be given it should be pressed so that the ap- 
pearance of slight puffing beneath the eyes, and a 
warning epigastric tenderness are produced. The 
paroxysms of headache should be treated just as the 
ordinary ague. With a very large dose or series of 
doses of quinine a few hours before their expected 
appearance. In one case lately seen, fifteen grains 
of antipyrine quickly broke up the headache, and I 
was not obliged to give a second dose. 

As most of these patients are anaemic and debili- 
tated, iron is naturally indicated. The tincture of the 
chloride is the best of these in combination with qui- 
nine. The arsenite of iron, or the water of the 
Rocegno spring of the Tyrol which is now imported, 
are worthy of a trial. 

Diabetic headaches are usually the precursors of 
more marked nervous symptoms, and especially coma. 
They are diffused and connected with dizziness, and 
more familiar indications of the disease. They are 
by no means as common as the neuralgia of the 
lower branch of the fifth nerve which is sometimes 
found, or of the sciatic. A diet which excludes starch 
and sugar, and the use of a carbonic acid water which 



- 76 - 

contains the carbonate of lithia and arsenic are the 
chief indications. The bromide of arsenic has been 
recommended. 

Tobacco, tea and coffee, or narcotic drugs may 
produce headache of anaemic or hyperaemic character. 
In most cases the diminution of the amount used, or 
its abolition is enough to effect a cure. The head- 
aches due to the injudicious use of the former are apt 
to be connected with more or less gastric disturbance, 
heart irregularity, fleeting pains about the cardiac 
region or back, coldness of hands, indisposition and 
muscular feebleness, and a feeling of distension 
with "tightness of the scalp." The pain is dull and 
attended with some "burning" of the eyelids, and 
there may occasionally be a sense of vertical pressure 
and light vertigo. Attacks of slight tinnitus are occa- 
sionally described. I know of no remedy which is so 
nearly an antidote to the bad effects of tobacco, and 
so quickly removes the headache as nux vomica, or its 
alkaloids. 

The headaches which result from immoderate 
coffee drinking have been called by Wood caffeinic. 
My own impression and experience is that the head- 
aches of both tea and coffee are after all due to gas- 
tric derangement with consequent malnutrition and 
anaemia, and not strictly toxaemia Any one familiar 
with dispensary practice recognizes at once the exist- 
ence of a digestive disturbance, which is probably a 
low grade of gastritis, and which prevails among 



— 77 — 

servants who drink large quantities of tea. This is 
usually helped by abstinence, and diet; and the head- 
aches cured by quinine and iron. It cannot be dis- 
puted that some neurotic persons cannot touch coffee 
or tea; and that insomnia, headache and a host of light 
nervous troubles result from persistent indulgence.. 

The consideration of headaches of various febrile 
states, and of a temporary nature more properly be- 
longs to works upon general medicine. 



CHAPTER V. 

NEURALGIC HEADACHES. 

A neuralgia of the fifth nerve is apt to be mani- 
fested by paroxysmal as well as dull pain, and by 
limited or general expression. No age is exempt, and 
men and women suffer alike. Its causes are various, 
and its duration and severity variable. If we consult 
any anatomical chart we may appreciate, how obscure 
is its origin in certain cases, especially those where the 
neural disturbance is due to some central change. In 
such instances, if the lesion be sufficiently profound, 
we may find not only pain, but disturbance of trophic 
function, and of the sense of taste in the anterior half 
of the tongue; as well as various anomalies in the 
functions of the parotid, lachrymal, and submaxillary 
glands. 

As the results of peripheral trouble; cicatricial 
and otherwise; anaemia or congestion of the nerve 
trunk; the pressure of bony or other tumors; reflex 
irritation from bad teeth; and a number of other 
pathological changes; we are furnished with a painful 
affection of the nerve which has been called trigeminal 
or facial neuralgia, and ophthalmic or supraorbital, 
infraorbital, dental and occipital neuralgia with refer- 
ence to the branches of the nerves that are involved. 
The pain is essentially paroxysmal, very agonizing 
when once established, and sudden in its onset. The 



— 79 — 
paroxyms in a well-established attack are so closely 
connected as to give the impression of continuous 
pain. The attacks of neuralgia in a chronic case, 
though occasional in the beginning, tend to become 
more and more constant, and are readily lighted up 
by any exciting cause, such as a cold draught, the act 
of eating very hot or cold substances, fatigue or pres- 
sure. The pain commonly begins in the supra-orbital 
branch of the trigeminus, and when developed, in- 
volves the entire side of the head, and when acute 
and general, we find lightning pains which affect this 
region, the back of the head as well, and the teeth of 
both jaws. 

At certain poi?its where the nerve branches be- 
come superficial, we find great tenderness. These are 
known as supra-orbital, palpebral, nasal, ocular and 
trochelar; infra- orbital, malar, superior labial; temporal, 
inferior dental, lingual, inferior labial, parietal, occipital, 
and vary as one of the three or all the divisions of the 
nerve are affected. During the course of a neuralgia, 
or afterwards, we find these painful spots. 

The neuralgic pain which involves the ophthalmic 
branch is a common and easily distinguished form. 
The pain runs over the side of the head, the nose and 
eye of the affected side, and is relieved somewhat by 
pressure over the supra-orbital foramen. The face 
may be flushed or pale, and the eye is bathed in tears, 
and there is hyperemia of the conjunctiva. In some 
cases there is a copious flow from the lachrymal 




Fig. 3. 

Superficial Distribution of Fifth and Seventh 

Nerves (Hirschfeld). 



Trunk of Seventh Nerve 
Posterior Auricular Branch of 
Filament of Great Auricular. 
Twig to Occipitalis 

41 Post Auricular N, 

41 Sup. 
Branch of Diagastric " 

" to Stylo-hyoid 
Superior Division of Pes anserinus 
Temporal Branches 
Frontal u 

Orbital 

Nasal " 

Buccal " 

Inferior Division of 
Labial 



21. 
22. 
23. 
24 
25- 
26. 
27. 
28. 
29. 
30. 
Si. I 

32- J 



Cervical 

N. Temporo- Auricular 

Supra- orbital 

Internal Frontal 

Palperal Twigs of Lachrymal 

Intra-Trochlear 

Malar Branch of Orbito-Malar 

Ext. Nasal Twig of Ethmoidal 

Infra-Orbital 

Buccal Branch of 5th 

Labial and Mental Branches of 5th 



Cervical Nerves. 



— 81 — 

ducts of the affected side, or the contact of air with the 
filiaments which supply the interior of the nose may 
result in sneezing, or, more rarely, a puffing up of the 
mucous membrane with obstruction. There is a pain- 
ful point above the eye — over the supra- orbital notch. 
Sometimes, as in the case of Anstie, the eyebrows or 
hair become the seat of a change of color, and dryness, 
brittleness or exfoliation are the consequences of re- 
peated and persistent attacks. Ross speaks of neuro- 
paralytic ophthalmia. In old cases of neuralgia we 
not only find trophic disorders such as I mention, but 
sometimes ulceration of the cornea, and persistent 
changes in color, consisting of pigment deposition in 
the skin. 

The anatomical distribution of the nerve will en- 
able us to trace the variety and character of the pain 
which symptomatizes neuralgia of the lower branches. 
Besides the painful points enumerated, we will find 
violent faceache and toothache which is more or less 
general. Sometimes the upper and lower rows of 
teeth on one side will be affected, or in one jaw alone. 
The mucous membrane of the mouth is exceedingly 
tender, perhaps tumefied, and in some cases a crop of 
herpes is present as the sign of an unusual attack. 
The tongue may be swollen. This, however, is rare, 
but it is common to find a tenderness of the gums, 
and sometimes a great increase in the amount of 
saliva secreted. 

The intra-cranial causes of neuralgia are very 

7 * 



82 



obscure. Vulpian reports a case of violent nature due 
to the perforation of the gasserian ganglion. (See 
plate.) Tumors, meningeal thickening, or the forma- 
tion of syphilitic or other adventitious deposits, may 



A-- 




Fig. 4. 
Vulpian's Case. 
A. — Bony spicula penetrating Gasserian ganglion. 

give rise to the affection, but it is a curious fact that a 
syphilitic deposit may completely surround a nerve 
without any impairment of function. 

Disease of the antrum or alveolar processes which 
is entirely unsuspected may give rise to severe neu- 



— 83 - 

ralgic disturbances. A gentleman from the West con- 
sulted me who was the victim of intolerable dental 
neuralgia wittvpainful shooting pains in the roof of the 
mouth, gums and pharynx. The slightest pressure upon 
any of the teeth of the upper jaw on the left side would 
inaugurate a paroxysm of neuralgic pain, which would 
finally involve the whole nerve. Soft food could be 
taken only in small quantities, and it was necessary to 
avoid extreme temperatures, for a mouthful of ice- 
water would cause intense neuralgic twinges. Two 
molars had been drawn without relief, and all methods 
of treatment were made use of unsuccessfully. Upon 
his return home a dentist extracted one of his bi- 
cuspids, which contained a verylong root, and this was 
removed with great difficulty. A profuse discharge 
of pus followed and after a few days the pain dis- 
appeared and never returned. 

The simpler cases of neuralgia due to cold 
(especially the ophthalmic form) malaria or gastric 
trouble, are relieved by anodynes, and the local use 
of galvanism. I have already spoken of the malarial 
headache which is often neuralgic, and have specified 
the antiperiodic remedies. It remains now for me to 
refer to the virtues of certain drugs which seem to 
have a decidedly specific action upon the trigeminus. 
The most important of these is aconite or its alkaloid 
aconitine. The tincture of the root may be used, 
in large doses, so that decided toxic efforts are 
produced; carefully feeling the way. Small doses are 



- 8 4 - 

almost useless. Perhaps the most convenient form of 
the drug is its alkaloid. Duquesnel's aconitia is the 
best, and the dose should vary from -g^th to -g^th of 
of a grain, to be repeated. A sufficient quantity to help 
the disease will produce some prickling of the tongue 
and lips, shivering, and a feeling of subjective cold- 
ness; and may even produce numbness of the ex- 
tremities. The pulse should be watched and the dose 
regulated with reference to the heart's force. It is 
unwise to give aconitia in pill form, or in a manner 
that may interfere with its solubility, and the danger 
of a cumulative dose is great. I have used it for years 
either in tablets (the Fuller method) or in solution. 

The plan of using aconitine adopted by Dr. 
Seguin and by him suggested to the N. Y. Thera- 
peutical Society is the following: 

1$ Aconitinae (Duquesnel's), gr. i-io to 1-6. 
Glycerinii, 

Spts. vini rec, aa 3 j. 
Aquae menth pip., ad § ij. 
M. Dose, 3 j t. i. d. before eating, to be carefully in- 
creased. 

Another remedy of value is the croton-chloral 
hydrate which also has a direct action on the fifth 
nerve. In doses of from fifteen to thirty grains, 
it is given in water and will occasionally modify the 
pain. 

The salicylate of soda, antipyrine or acetanilide 
have been spoken of before in connection with other 



-8 5 - 

forms of headache. They are all useful in neuralgia. 
Wilks recommends chloride of ammonium in fifteen 
grain doses, three or four times daily, but I believe 
this does good only in a limited number of cases, 
and these are not examples of true neuralgia, but 
migraine. 

Tonga, a Fiji remedy of great local reputation, 
has been extensively employed in England and 
America. It is of unquestioned value in some cases 
of supra orbital neuralgia, and may be administered 
in the form of a fluid extract, and in doses of from 
one to two teaspoonsful, to be repeated. 

Cimicifuga, in combination with aconite and bella- 
donna, has been recommended by Metcalfe in sciatica. 
I have also used the combination in facial neuralgia 
with success. Equal parts of the tincture of cimicifuga 
racemosa or actea racemosa, tincture aconite root, and 
tincture belladonna are to be combined, and doses of 
six drops are to be repeated every hour until relief or 
physiological effects are produced. 

Ammoniated copper has been praised by the 
French writers. I have never found it reliable and 
hesitate to recommend it. 

The treatment of the general condition which 
leads to the development of neuralgia is important. 
Arsenic, iron, cinchona and its alkaloids; alteratives 
such as mercury and the iodides, the phosphate of sil- 
ver, and many others makes a formidable list. I have, 
in speaking of anaemic headaches, given some formulae, 



— 86 — 

and here have nothing more to add except it be to 
reiterate the advice that the exhibition of all drugs of 
a restorative nature should be in large doses. The 
silver salts are indicated in inveterate cases, and I 
prefer the tribasic-phosphate of silver to any other 
— even the nitrate. It should be given with argil- 
laceous earth, for the confection of roses, and other 
vegetable excipients are very apt to decompose the 
silver salts which are exceedingly unstable. 

Some chronic cases are materially benefitted by 
Donovan's solution an old and valuable combination, 
and others by the use of one of the iodides of mercury, 
preferably the red. The salicylate of iron may be sug- 
gested in cases of gouty origin. 

In sub-occipital neuralgia, which is commonly of 
malarial origin I place great reliance upon large 
doses of quinine carried to the point of cinchonism. 

In cases of facial neuralgia with zona ophthal- 
mica or herpes, there is no better remedy than that I 
have just mentioned, in addition to galvanism. In fact 
the indications are those which lead us to select the 
same treatment in herpes zoster. 

Phosphorous in its pure form is one of the best 
regenerators of diseased nerves in existence, and in 
neuralgia of the fifth nerve is an excellent agent. 
The solution in absolute alcohol which I believe was 
first recommended by Thompson, of England, is an 
admirable preparation and produces little or no gastric 
disturbance. 



- 87 - 

5 Phosphori, gr. i. 

Alcohol absolut., q. s. ut dissolv. 

Glycerini, ad § iv. 

Spts. menth. viridis, 3 ss. 
M. 
Sig. One teaspoonful after eating, to be increased. 

The phosphorated oil in capsules, or pills of pure 
phosphorus made up with bread crumbs, are good 
preparations, as is the combination of pure phosphor- 
us and sulphur. 

The actual cautery may be used with benefit in 
cases where there are well-defined painful points. A 
small platinum tip is to be employed, and the hyperaes- 
thetic area whether it be in the scalp or elsewhere may 
be lightly touched. In cases of neuralgia of the 
great occipital this therapeutical measure is one of 
importance. 

The bisulphide of carbon has been used as an 
external irritant. Gasparini has treated fifteen cases 
successfully, and his method is to apply to the painful 
point cotton-wool saturated with bisulphide. A few 
drops of the essence of peppermint will disguise the 
offensive odor. 

External applications of ointments or liniments 
which contain anodyne substances sometimes do good, 
especially when there is much diffused hyperesthesia. 
Among these are menthol, morphine, veratria, aconite, 
and belladonna; hypodermic injections of aconite, 
belladonna or daturia or osmic acid are at times 
beneficial. 



— 88 — 

An ointment containing morphine and veratria 
is sometimes excellent, and the following formula is 
recommended : 

1$, Veratrinae, gr. x. 

Spts. vini recit., Ttyxxx. 

Morphinae sulph., gr. xx. 

Vaselini, § ss. 
M. Sig. For external use. 

Bartholow recommends the oleate, and an oint- 
ment made up with benzoated lard. 
" Oleatum veratrinae: " 

3 Veratrine, 2 parts. 

Oleic acid, 98 parts. 
M. 

" Unguentum veratrinae : " 

3 Veratrine, 4 parts. 

Alcohol, 6 parts. 

Benzoinated lard, 96 parts. 
M. 

Very great care should be exercised in using 
these preparations as well as aconite embrocations, 
and the hands should always be washed after their ap- 
plication. 

An ointment prepared by the combination of 
equal parts of chloral and camphor, with vaseline is a 
useful external application: 

B Chloral hydrat., 

Camphorae, aa 3 ij . 

Vaseline, § ss. 
M. 

and we may add morphine to the prescription. 



- 8 9 - 

Various observers have used cocaine in neuralgia 
of the fifth nerve, both hypodermically and by appli- 
cation to the fauces and nasal fossae. Papoff cured 
one bad case by local hypodermics of a 10 per cent, 
solution, using about half a syringe full. In one case 
of which I know when it was used by a dentist, and 
injected in the neighborhood of* the inferior dental 
nerve, it produced facial paralysis, but I am unable to 
find others which contra-indicate its use. In some 
neuralgias due to catarrhal rhinitis, it promptly re- 
lieved the pain when it was used in the atomizer. 

An excellent remedy in vogue in the country is a 
tincture made from the fruit of the belladonna. The 
berries should be crushed when green, and covered by 
strong alcohol. This makes a valuable external ap- 
plication. 

Sclapiro* lays great stress upon the value of 
osmic acid. He cured five of eight cases and relieved 
the others. His formula is the following: 

I£ Osmic acid, gr. 1-6. 

Distilled water, 3 iss. 

Pure glycerin, 3 j. 
M. 

This preparation keeps two weeks, but without 
the glycerin readily decomposes. TfJJv should be given 
hypodermically, and several injections are often neces- 
sary. Neuber has injected as much as 3 centigrammes 



* Der Fortschritt, Dec, 5, 1885, No. 23. 



— 9° — 

of osmic acid within a period of three months without 
any bad results. 

The use of cold obtained by means of the spray- 
producer is strongly advised. Some years ago I em- 
ployed sulphuric ether for this purpose. The appli- 
cation should be made just in front of the ear over 
the painful points. The nasal injection of carbonic 
oxide, as recommended by Dupre and Brown-Sequard 
some years ago, is, I believe, a useless or at least un- 
reliable mode of treatment. 

Debove, Vinay, Peyronnet de Lafonville and 
Jacoby have all used with greater or less success the 
spray of methyl-chloride in the treatment of neuralgia 
of the fifth nerve. The primary results are freezing 
and anaesthesia, followed by redness and hyper- 
esthesia which subsides after a while, with a disap- 
pearance of the pain. An accident to be avoided is 
vesication. 

I have devised a method of applying cold to a 
small territory which will often break up an attack of 
neuralgia. This consists of the adoption of a large 
felt-covered test tube, which is filled with finely-crack- 
ed ice and salt, or muriate of ammonia. An intense 
cold is produced, and the convex end, which is un- 
covered, may be applied to the sub-orbital foramen, or 
over any or all of the painful points in turn. The 
advantages over ether is the absence of danger where 
there > are lights or fires, and of the odor of the 
latter, which often nauseates the patient. 



— 9 I — 




"<^BS» 



Fig. 5. 
Apparatus for Using Methyl-Chloride.* 

" In use, the direction of the spray having been 
determined by means of the thumb-screw c, a slight 
turn is made at b by means of the key e; this allows 
the vapor to pass into the tube connected with d; by 
turning d the amount and duration of the spray is 
regulated." 

The treatment of neuralgic pains by vibrations as 
suggested by Mortimer Granville, Boudet and myself 
may be resorted to. The electrical apparatus devised 
by me, and afterwards modified by Boudet, may be 
employed. It is simply a flat piece of hard wood, on 



* The above apparatus may be procured from Messrs. 
Mc Kesson & Robbins, of New York City. 



— 92 — 
which is mounted a vibrating tuning fork, actuated by 
a strong magnet. The current is supplied by a 
bichromate or other battery. The board is fitted 
with a projecting rod terminating in a knob which is 




Fig. 6. 
to be pressed against the painful point. When the 
current is connected the vibrations of the tuning fork 
are transmitted to the rod and in turn to the nerve. 
Though not uniformly beneficial, the use of the vibra- 
tor is often curative.* 



*Also see reference to author's instrument and more ex- 
tensive details in " Nervous Diseases, Their Description and 
Treatment." H. C. Lea's Sons & Co. Philadelphia. 1881. 
Second Edition. 



— 93 ~ 

Faradization or massage of the scalp are to be re- 
sorted to in severe cases with a decided prospect of 




Fig. 7. 
Points for electrization and cauterization of painful points. 

benefit. The former, if not too strong, will soothe the 
patient, but if violent currents are applied there will 
be a decided aggravation of the pain of the neuralgia 



— 94 — 

itself. A mild current passed through the hand of the 
operator — the patient holding one of the poles will 
often produce a feeling of drowsiness, and is followed 
by a subsidence of the paroxysm. The " wire brush " 
may be passed over the painful tracts. 

In neuralgias of rheumatic origin when there are 
painful points, and tenderness which lasts several days, 
the use of an ordinary wire hair-brush with connec- 
tions with the faradic battery; or light massage of the 
scalp (care being taken not to pull the hair), will be 
found to diminish the hyperesthesia. In sub-occi- 
pital neuralgia faradization is highly efficacious. 

The galvanic treatment of neuralgia of the fifth 
nerve is of immense importance, and it is generally 
recommended by the authorities upon nervous diseases. 
Small electrodes with sponge or chamois-covered heads 
are the best, or we may use a carbon-tipped electrode 
which may be covered with absorbent cotton. If cur- 
rents of high tension or quantity are selected, it will be 
better to use an electrode with greater surface, other- 
wise we may cause intense pain when the smaller elec- 
trode is placed, as well perhaps as vesication. The 
cathodal electrode should be applied firmly on the 
tender points, and the anodal electrode just anterior 
to or below the ear. Currents that produce vertigo 
are to be avoided, and do no good. Daily applica- 
tions of five or ten minutes duration are usually suffi- 
cient. In some cases the patient may be relieved by 
galvanization of the interior of the mouth. 



— 95 — 

For the relief of sub-occipital pain I have used 
nuchal applications of Gaiffe's revulsive disk with en- 
couraging success. 

Rosenthal has suggested the moist pack for one- 
half hour to an hour at a time in rheumatic cases, fol- 
lowed by galvanism. Static electricity, except in these 
cases, is of little or no use. 

*Rasori, of Rome, has used the tuning fork in the 
treatment of neuralgia, applying it while vibrating 
over the course of the painful nerves. 

The instrument was applied from 20 to 40 min- 
utes. It also relieved nervous vomiting. 

Tic douloureux (or prosopalgia) is best relieved 
by gelsemium — in fact I regard it as the best remedy 
at our disposal, but it must be given in large doses, 
and at least a mild toxic effect should be produced. 
From two to six or even eight minims should be the 
initial dose, and this may be increased. In the case 
of a medical friend who had taken an overdose by 
mistake, an epileptiform tic of several years standing 
was suddenly and completely cured by an overdose 
taken by mistake, which produced semi-collapse and 
many alarming symptoms. Croton chloral in 
twenty-grain doses sometimes does good, and Bram- 
well curedf a case by the use of drop doses of the one 
per cent, solution of nitro-glycerin thrice daily. 



* The Journa) of Nervous and Mental Diseases, Oct. 1, 
1883. 

f British Medical Journal 1884, p. 609. 



_ 9 6 _ 

* Dr. R. G. Simpson has reported a case where 
ice cap relieved tic douloureux when even morphine 
had failed. 

Surgical measures are often necessary and may 
consist of traction, exsection, or those calculated to re- 
live periostitis or disease of the antrum. Of the first 
of these I cannot speak in commendation, for the re- 
sults are by no means permanent, and sometimes re- 
sult in dangerous complications. A year or two ago 
it was a fashionable and sometimes successful opera- 
tion. Lemaistref has written fully upon his success, 
and details a number of experimental observations 
made by him with a view to determining the expen- 
diture of force. A tension force equal to 8.83 lbs. 
was needed to stretch the nerve, and that there was 
never laceration of the gasserian ganglion, he explains 
by the protection afforded to this organ by the dura 
which covers it. Lemaistre prefers nerve stretching 
to the operation of Carnochan, which consists in 
breaking through the walls of the antrum. 

Various other forms of nerve stretching have 
been suggested for prosopalgia. Ledentu has stretch- 
ed the lingual nerve for a tic of five years standing, 
the nerve being elevated 12 mm. on a hook; and 
Polaillon has stretched the inferior dental, first trephin- 
ing the inferior maxilla. 

Nerve section is after all the only effectual method 



* Cincinnati Lancet and Clinic, Oct. 20, 1883. 
f Revue de Chirurgie, 1882, No. 12. 



— 97 — 

of curing obdurate neuralgia, but as many surgeons 
know, this operation affords only temporary relief un- 
less it is extensive or thorough, and the following case 
of Richardson is an example in point. The first neu- 
rectomy was insufficient, the second effectual. 

" Neuralgia of inferior dental nerve for five years. 
Division of nerve inside mouth; relief for two years. 
Return of pain in aggravated form, lasting one year. 
One inch of nerve destroyed by opening inferior 
dental canal from outside. Immediate recovery and 
cure. 

" S. P. B., seventy-two years old, entered Sept. 
3, 1886. Eight years ago, developed severe neuralgia 
in the right side of the face, over the lower jaw. 
Three years ago, inferior dental nerve was divided 
just above the point where it enters the dental foramen. 
This operation gave relief for two years, when the 
same trouble returned. 

"August 4th. One inch of the inferior dental 
nerve was cut out. An incision parallel to, and 
through the fibres of the masseter muscle, three inches 
in length, was made down to the jaw-bone. With a 
gouge and mallet a narrow opening, one inch long, 
was made through the ramus of the jaw over the 
dental canal. The nerve and artery thus exposed 
were cut at each extremity of the opening, and the 
whole curetted out. There was little haemorrhage. 
The external wound was closed with silk, and iodo- 
form dressings applied. 



8 R 



- 9 8 - 

" Two days later, stitches and drainage-tube were 
removed. For some days after the operation there 
was complaint of slight pain in the parts supplied by 
the mental branch of this nerve. This rapidly disap- 
peared. He was discharged on the ioth. 

"August 25th. Came and reported that 'it was 
a real -pleasure to live; that he had had more real 
pleasure in life since leaving hospital than in any ten 
years before.' " 

Epileptiform tic or prosopalgia has been cured by 
Perkovsky by division of the auriculo-temporal nerve. 
An incision ten centimeters long and five millimeters 
deep, should be made between the condyloid portion 
of the lower jaw and the anti-tragus. 

Cadge* reports four cases of tic by neurectomy. 

Richardsonf in an admirable report upon neural 
operation, reports the following case of neurectomy 
for tic: 

"Epileptiform neuralgia" of side of nose and 
face. Neurectomy of infra-orbital nerve; complete 
•cure. 

Tim O'Brien, sixty, married, laborer; entered 
hospital- August 8, 1885, with history of trouble in 
face for sixteen years. Some years ago had an opera- 
tion done in an English hospital, without relief. Has 
pain in right side of face and nose, in parts supplied 
by the infra-orbital nerve. This is spasmodic, and 



* British Medical Journal, July 15, 1882. 

f Boston Medical and Surgical Journal, Oct. 21, 1886. 



— 99 — 
extends from the inner canthus of eye down to the 
ala of the nose. During this paroxysm he leans 
his head upon his hands, with evidence of great 
pain, and the muscles of the nose contract spasmodic- 
ally upon the right side, drawing up the ala and 
wrinkling the skin. 

August 12. Under ether, the infra-orbital nerve 
was found, a needle having been first inserted into the 
infra-orbital canal. The nerve was pulled out of the 
canal as far as possible, and cut. The peripheral end 
was then drawn up, and its branches dissected down 
an inch or more, and then divided. 

The next day patient reported himself very com- 
fortable, with pain much relieved. What pain still 
existed was referred to the ala of the nose. 

August 18th. Five days after operation the pain 
had entirely left the face. 

August 2 1 st. No return of pain; face healed. 
Discharged. 

In neuralgia of the inferior maxillary nerve, an 
infra-buccal operation is the easiest and best, and it 
may be divided just before it enters the dental canal. 

Heustis* has cured a case of infra-orbital neural- 
gia by cutting down and exposing the infra-orbital fora- 
men and drilling back as far as the spheno-maxil- 
lary fissure with a fine dentist's drill, thus removing 
the nerve. 

Severe measures are often imperative, and re- 

* Medical News, Dec. 8, 1883. 



IOO 

moval of Meckel's ganglion is an operation which often 
suggests itself. 

Dr. Vanderveer* has cured two cases of infra- 
orbital neuralgia by removal of this ganglion. In one 
case the neuralgia remained absent for eight years. 
In another case there was no cure, and it was found 
that there was disease of one eye. However, when 
this was removed the patient recovered. 

Dr. Vanderveer's first case and the operation 
therefor is the following: 

"Miss B., aged 40, first consulted me July, 1875, 
giving the following history. For three or four years 
previous she had suffered from neuralgic pains in 
right side of the face, differing as to length of time 
and degree of severity. Her general health up to 
this time had been good. Passed the menopause 
about two years before. Since that time she had had 
little relief from pain unless under the influence of 
medicine. All her teeth had been removed (one or 
two at a time) from right side upper jaw, and some 
from the lower jaw on that side, with but little, if any, 
relief resulting. Had taken medicines almost con- 
stantly. For the previous six months she had had no 
remission of pain, though taking large doses of mor- 
phine, chloral and bromides. The pain would start 
in the upper jaw, extend over the face, pass down, 
around and through the lower, to chin and along 
right side of tongue, also penetrating the temporal 



* N. Y. Medical Record, June 9, 1883. 






101 

region, leaving a heat or inflammation in the mouth, 
very severe. 

"At times she would be unable to take a drink 
without having the pain aggravated for hours. 

"I gave her large doses precip. carb. iron; also 
Brown-Sequard's neuralgic pills, but with no apparent 
benefit. Gave hypodermic injections chloroform with 
a few moments' respite from pain, but the inflamma- 
tion following was very severe. Also gave morphine 
in the same manner, but so little good followed that 
she readily consented to an operation. 

" On September 5, 1875, ether being given, I pro- 
ceeded to remove the infra-orbital nerve and Meckel's 
ganglion in the following manner: Making an in- 
cision from the right angle of the eye, down to the 
bone, along the nerve at a distance of little more than 
an inch; then another incision, similar in length, at 
right angles, under the infra-orbital ridge, raising the 
flap and periosteum, I exposed enough of the anterior 
wall of the antrum to admit the application of a good- 
sized trephine, removing a button of bone, so that the 
upper edge, opening, exposed the infra-orbital nerve 
and its canal. Lifting the nerve from its bed by means 
of a bone chisel, grooved director and probe, I follow- 
ed it until the posterior wall of antrum was reached, 
where, by means of a smaller trephine, another button 
of bone was removed, and the spheno-palatine fossa 
reached. The ganglion was now lifted from its bed 
and, with curved scissors, the nerve and it were sever- 



102 



ed and removed. This was followed by a sharp 
haemorrhage, and at first somewhat alarming, but 
controlled by portions of sponge, firmly applied, to 
which a silk ligature had been tied. The wound in 
the face was then closed by interrupted sutures, a 
drainage tube, with ligature from sponge, being placed 
in most dependent point. The patient rallied nicely 
from the anaesthetics, and was immediately relieved 
from all pain. There was considerable trouble in re- 




Fig. 8. 

moving the sponge, and the parts suppurated quite a 
good deal, but ultimately healed kindly. From that 
time on she has been in perfect health, increasing in 
flesh, attending fully to her work, and a more grate- 
ful patient I have never seen. * * * * 
By taking out a good-sized button from the posterior 
wall of the antrum, and watching carefully, the in- 
ternal maxillary artery can be seen pulsating, and 
thus avoided, while a most excellent view of the 
ganglion can be obtained. As with all operations 
upon the nerves, I am convinced the operation needs 
to be done thoroughly; if not, failure is likely to re- 
sult, as it will, in cases where the pathological lesion 
is still more central and the cause not peripheral. In 
lifting the infra-orbital nerve from its bony canal, I 
found, in my last operation, the instrument here shown 



— io3 — 

figured of great service, as by its use the operator is 
not so likely to tear or separate the nerve — something 
very important to avoid, for, by keeping the nerve in 
its continuity, he has a sure and safe guide .to and 
along the ganglion." 

In a patient with stubborn neuralgia of the infra- 
maxillary branch of the nerves, Hach found a large 
granulation at the back of the pharynx, and when this 
was cauterized the patient's pain left almost as by 
magic. It cannot be questioned that disease of the 
nasal fossa, or middle ear troubles are at the bottom 
of many neuralgias. 

Gross* has described a form of neuralgia, met 
with chiefly in elderly persons who have lost their 
teeth. It is confined chiefly to the upper jaw, and 
depends upon a low grade of periositis with deposits 
of bony material and pressure of the smaller nerve 
filiaments. 

Some neuralgias may be cured by empirical 
means, and that reported by Durham is one in 
point. Durham vainly tried to relieve an inveterate 
supra-orbital neuralgia by stretching the superior 
branch; only temporary comfort was obtained, but 
when the trephine was applied over a cicatrix upon 
one side of the head, which had been left by the kick 
of a horse, it was found that an immediate cure was 
effected. 



* Am. Journal of Med. Science, vol. lv, 1870, p. 48. 



— 104 — 

The simple excision of old cicatrices is often im- 
perative, even when no bone disease is suspected, but 
when there is periositis and necrosis, it is absolutely- 
necessary to resort to appropriate surgical measures. 



CHAPTER VI. 

NEURASTHENIC HEADACHES. 

Under this head comes a long list of irregular 
headaches of obscure causation, but dependent more 
or less upon conditions of neural weakness. The 
headaches of neurasthenia include some already 
spoken of as anaemic. They have oftentimes an 
hysterical element, or depend upon reflex mischief. 
Oculists have for a long time recognized the head- 
ache from eye-strain; gynaecologists, those from 
ovarian and uterine disorders. 

Hysterical headaches are likely to be of the most 
varied description, and but one form is at all charac- 
teristic, that known as clavus hystericus. This consists 
of an intense and localized head-pain, which has been 
compared to that which might follow the driving 
a nail into the head. It is nearly always vertical. 
Hysterical women are very apt to complain of very 
great diffused hyperaesthesia of the scalp, so that the 
simple act of brushing the hair causes great distress. 
All hysterical headaches are worse at the catamenial 
periods, and are aggravated by fatigue, excitement, 
late hours, etc. There is often attendant ovarian irri- 
tation or backache, and much mental irritability. The 
pain of clavus is rather intractable, and actual re- 
sources toJ:he hypodermic injection of morphine and 



— 106 — 

atropine is sometimes absolutely necessary. These 
patients are more apt than any others to form the 
opium habit, or that of alcoholism, and great care 
should be taken lest, by yielding to their demands, we 
foster something worse than the headache or hysteria. 

External applications of the wire brush with 
mild faradic currents will often mitigate the suffer 
ing, and should this fail, we may resort to the ether 
spray. Massage to the head is recommended by 
Webber, but it is by no means agreeable to all 
patients. The citrate of caffeine or bromide of caffeine 
are often serviceable. Valerinate of ammonia and 
cypripedin are also useful. The latter may be used 
in the form of the fluid extract, and dram doses fre- 
quently repeated will be found to increase the patient's 
comfort. 

The following formula is recommended: 

1$ Ammon carbonas, 3 iij. 

Tr. moschi, 3 vj. 

Spts. lavandulae, § i. 

Elixir ammon valerianas, ad 1 viij. 
M. 
Two teaspoonsful at a dose, in water. 

».. A rectal injection of half an ounce of the tincture 
assafcetida in a pint of thin starch water will not only 
help these headaches, but is useful in other hysterical 
troubles, notably those of a convulsive nature. Most 
patients of this kind need iron and it may be given in 



T— I07 

eombination with small quantities of the.hydrochlorate 
of cocaine. 

5 Cocaini hydrochlor., gr. iv. 

Ferri et strychniae citras, gr. xxiv. 
Ext. gentianse, gr. xlviii. 

M Ft. massae et divid in pillulae, No. xxiv. 
Sig. One after each meal. 

The iodide of iron is often more serviceable than 
any other preparation especially in combination with 
Calumbo. 

Great good results from the application of the ac- 
tual cautery, or blisters over the ovaries, and in many 
cases the left ovary will be found hypersesthetic. 

The headaches of exhaustion have been alluded 
to before under the head of cerebral hyperemia. It 
remains for me to call attention to a variety which 
bears no relation to the condition of emptiness or ful- 
ness of the blood-vessels of the brain — a headache, 
in fact, with exhaustion of the nerve cells. Such a 
cephalalgia always follows unusual fatigue, be it mental 
or physical; is occasionly frontal, but more often verti- 
cal, and is neither paroxysmal or sharp. It disappears 
sometimes quite promptly after a glass of whiskey 
and water, or champagne; or a good night's rest. The 
faculties are often pre-naturally active, and the indi- 
vidual is mentally hyperaesthetic. He may have insom- 
nia, but his sleeplessness is of the quiet kind, and he 
simply lies wide awake and there is no tossing, heat 



— io8 — 

of head, or anxiety. The surface of the body may 
be cold and the face pale. 

Diffusible stimulants bring relief as does the " phos- 
phoric acid lemonade," which may be made by the 
addition of a few drops of lemon juice and a lump of 
sugar to a half teaspoonful of dilute phosphoric acid 
and a tumblerful of water. A new preparation, the 
benzoate of sodium and caffeine, may be given in five 
to fifteen grain doses hourly. Guarana or the fluid 
extract of paullina sorbilis in tablespoonful doses. 
Cocaine in doses of one-half of a grain. Strong 
coffee or green tea are excellent abortants of an at- 
tack of headache of the kind. Wurm has given qui- 
nine or morphine in combination with guarana with 
excellent effect. In the cases where it is useful, dry 
heat to the head is more agreeable than cold or ice 
compresses. A glass of very dry champagne, or a 
teaspoonful or two of absinthe which have been poured 
over finely cracked ice, are also recommended. 

The most efficacious preparations for continuous 
treatment are those of the restorative class. A pill of 
the arseniate of strychnine, strophanthus and quinine is 
recommended. 

1$ Strychnine arsenias, gr. ss, 
Sem. strophanthii pulv., gr. vi, 
Quinae sulph., gr. xlviii. 

Ft massae et divid in pillulae No. xlviii. 
M. Sig. — One to two after each meal. 



— 109 — 

A stimulating preparation of iron may be sug- 
gested, and I know of none better than the ethereal 
acetate. This may be given alone or in combination 
with strychnine. 

§ Strychniae acetas, gr. ss — gr. i, 
Tr. ferri acet ether, 3 vi, 
Aquae lauro cerasi, § iv. 
M. — One teaspoonful after eating in water. 

Iron and ignatia, perhaps in combination with 
arsenic may be prescribed with advantage. 

E Ignatiae, 

Acidi arseniosi, aa gr. i, 

Ferri redacti, 

Ext. gentianae, aa gr. xl. 

Ft massae et divid. in pillulae No. xl. 
M. — One after each meal. 

Besides iron, we may make use of one of the 
preparations of phosphorus before enumerated. 

Burgess * recommends the use of aconite for the 
treatment of the headache of exhaustion, and it maybe 
used mainly in small repeated doses of one or two 
minims until relief is obtained. 

General hygienic measures, such as bathing and 
massage, head shampooing, and rest as far as possible; 
change of scene and air are necessary and important 
adjuvants. 

Certain vague headaches have been called 



^Edinburgh Medical and Surgical Journal, 1840, p. 95-105. 



— no 

"sympathetic." The application of this term must 
lead to confusion, for little or no attention is paid to 
the actual pathological state. The same fault may be 
found with the term " nervous." All practical men 
recognize the existence of irregular headaches from 
gastric, hepatic, or visceral disorders generally, and 
each case must be studied from a different standpoint, 
and the individual indications properly met and over- 
come. 

Various remote disturbances which tax nervous 
energy to its utmost, or a constant, remote, and often 
unsuspected irritation are productive of these head- 
aches. In women they are closely related to the 
menstrual periods, or with the condition of the diges- 
tive organs. Following upon the ingestion of rich or 
improper food they symptomatise a gastric irritation. 
Some people call them " bilious," though the function 
of the liver may in every way be normal. 

I have already alluded to a form of headache in 
which ovarian irritation plays a part, and in such cases 
it is not unusual to find leucorrhcea, backache, 
coldness and clamminess of the hands, insomnia, 
palpitation and muscular feebleness. 

The so-called " bilious " or stomachic headache 
usually affects individuals who present epigastric un- 
easiness, eructations of acid fluids, sudden hunger 
which is easily appeased. " sinking " sensations, 
cardiac distress, flatulence; and a decided atony of 
the bowels which is manifested by alternating consti- 



— Ill — 

pation and looseness. The stools are not; well formed. 
Iced or very hot drinks taken into the stomach often 
produce immediate head pain which is frontal, and 
an acute attack of indigestion is the origin of a reflex 
headache which may be vertical, and not attended by 
any signs of disturbed cerebral circulation: 

A cause of " sympathetic " headaches originates in 
the irritation from bad teeth which need not neces- 
sarily produce neuralgia, and the reflex irritation at- 
tendant upon the appearance of the wisdom teeth 
often gives rise to headaches of a diffused and almost 
constant character, which only ceases with complete 
dentition. . Aural disease is perhaps a more common 
cause of headache than we imagine. It may, or not 
be attended by tinnitus, but often is by vertigo, which 
may be general or lateral. Not only may disease of 
the organs of hearing produce a neuralgia or a head- 
ache which affects the side of the head and is dull 
and accompanied by tenderness, but there is a re- 
flected irritation which may be the starting point of a 
genuine sympathetic headache. 

Besides the proper surgical or mechanical measures, 
such as operation, syringing, etc., we may administer 
strychnine in large doses, or belladonna. I have had 
unusual success with the latter drug pressed to the 
point of tolerance. The removal of a plug of wax 
will sometimes cure headaches that have defied many 
remedies, and warm syringing will decidedly amelior- 
ate the patient's suffering. 



112 

Dr. Harrison Allen, of Philadelphia, has called 
the attention of the profession to a purely nervons 
headache due to catarrhal disease of the nose. The 
pain he considers reflex, and it is confined to the side 
of the head and face and sometimes the vertex. 
Wood says that the patient can often define it by 
"drawing the index finger across the face from the 
middle of the nose to the temple, and thence in some 
cases to the parietal eminence." Sometimes the pain 
resembles migraine and is associated with nausea. 

It has been the fashion of late to ascribe to dis- 
orders of accommodation and refraction, not only 
many forms of headache, but other nervous dis- 
orders as well, such as epilepsy and chorea. Certain 
disingenuous or ignorant persons have even claimed 
to cure posterior spinal sclerosis, and degeneration 
of the pyramidal columns of the spinal cord by ocular 
myotomy; and all manner of extreme operative inter- 
ference, which smacks strongly of charlatanism, has 
been indulged in. 

The existence of headaches due to eye-strain 
has been recognized for years by those who have 
made the eyes a study, and the provision of proper 
glasses and treatment calculated to improve the tone 
of the ocular muscles has often been promptly fol- 
lowed by substantial relief. The location and char- 
acter of pain vary greatly, but as a rule the former 
is either suboccipital or frontal. Some ophthalmol- 
ogists ascribe the sub-occipital pain to accommoda- 



— H3 — 

tion weakness, and the frontal headache to refractive 
disturbance, but others are equally sure there is no 
constancy in the connection. The headache of eye- 
strain is of course produced by reading, and aggra- 
vated by persistent use of the eyes, and by bright 
lights. It is dull and continuous, and may be accom- 
panied by lachrymation and photophobia. 

Hypermetropic persons are those who most often 
suffer from headaches of this character, and with the 
hypermetropia there is often considerable astigmatism. 
Myopic persons, through injudicious use of their 
eyes, also suffer from dull, persistent vertigo and a 
great deal of distress. The victims of ocular head- 
aches, as a rule, have red swollen eyes, and when the 
inner surface of the lids is exposed, there will be 
found a low grade of inflammation with granulation. 
Through insufficiency of the recti, a variety of mus- 
cular asthenopia occurs with headaches. This is de- 
veloped by close application to fine work, and obstin- 
ately resists ordinary treatment. After the patient's 
power of ocular adduction or abduction is determined 
by means of prisms, a pair of concave glasses may be 
selected, or prisms may be provided to overcome the 
weakness of the recti. In hypermetropic headaches, 
convex glasses are indicated, and at first those of low 
power may be provided, which are to be afterwards 
increased. 

Some observers have noted a variety of migraine, 
which is due to eye-strain and differs but little from 
q r 



— ii4 — 

the common forms, except, perhaps, that it is more 
localized. 

There is a form of headache from mechanical 
vibration which is neurasthenic, and I have met with 
it among railroad men or machinists. It is diffused, 
present a great deal of the time, and attended by 
mentaljhyperaesthesia. When it is possible the pa- 
tient should be made to discontinue his work and seek 
rest, but if this cannot be done, the treatment should 
consist [in cerebral sedatives, the bromides ranking 
first. 



INDEX. 



PAGE. 

Ability to Locate Pain 2 

Acetanilid 46 

Aconite in Neuralgia 83 

Actual Cautery 87, 107 

Alcohol 28 

Alcoholic Headache 6 

Alkaline Baths 11 

Ammonia, Valerianate of 106 

Anaemic Headaches 52 

Rest Treatment in 52 

Angio-Paretic Migraine 20 

Angio-Spastic Migraine 35 

Antifibrine 46 

Antipyrine in Neuralgia 84 

Antipyrine 46 

Antrum, Disease of 82 

Arseniate of Strychnine 10S 

Assafcetida 1 06 

Aural Disease as Cause of Headache in 

Bad Teeth 46, 11 1 

Baths, Alkaline 11 

Baths, Needle 26 

Benham on Cold 28 

Benzoate of Sodium and Caffeine 108 

Betol 50 

Bromide of Ammonium 35 

Bilious Headache no 



— n6 — 

PAGE. 

Caffeine Bromide 106 

Citrate 106 

Caffeinic headache 76 

Cannabis Indica . 35 

Case, Vulpian's 82 

Cerebral Anaemia of Aged People, 44 

Chloride of Ammonium S5 

Chloroform 12 

Classification of Headaches 3 

Clavus Hystericus 105 

Cocaine 108 

Cod-Liver Oil 14 

Congestive Headaches 5 

Causes of 7, 8 

Symptoms of. . . 5 

Cold, Benham on 28 

in Neuralgia 90 

Coming's Method 30 

Connection of Visual Defects 113 

Cracked ice go 

Croton Chloral 84 

Cypripedin 106 

1 

Diet in Anaemic Headaches 44 

Lithaemic Headache 67 

Diabetic headache 75 

Division of Inferior Dental Nerve 98 

Donovan's Solution 86 

Duquesnel's Solution 84 

Epileptiform Tic, Division of Auriculo-Temporal Nerve in. 98 

Ergotin 17 

Ergot 16 

Excision of Cicatrix in Neuralgia 103, 104 



— H7 — 

PAGE. 

Excretion of Uric Acid in Gouty Headache 67 

Exhaustion 107 

Eye Strain as Cause of Headache 112 

Faradization, General 53 

Facial Neuralgia 78 

Formula for Osmic Acid Injection 89 

Fothergill in Regard to Anaemic Headache 34 

Fothergill's Solution 23 

Fork, the Tuning 95 

Gaiffe's Disk 95 

Galvanism 30, 94 

Gouty Headache 67 

Gas, Nitrous Oxide 39 

Oxygen 39 

Gout, Quiet 68 

Haig on Diet 67 

Haemophilia as Cause of Anaemic Headache 36 

Headache, Alcoholic . 6 

Aural Disease as a Cause of 1 11 

Bad Teeth as a Cause of in 

Bilious no 

Bitter Tonics in 6 

Bromides in 12 

Brain- work as a Cause of 7 

Caffein in 76 

Canabis Indica in ... 35 

Cerebral Surgery for Relief of 64 

Cholaemic 71 

Cerebral Tumor a Cause of 60 

Classification of 3 

Diabetic 75 

Digitalis in 7 



— n8 — 

PAGE. 

Headache, Defective Hygienic Conditions a Cause of 31 

From Debauch 5 

Gouty 65 

Heat 7 

Hysterical 105 

Ice-bags for Relief of 7 

Isolation as a Cause of 7 

Lithaemic 65 

Location of 2 

Malarial 74 

Meningeal 59 

Naphthalol in Treatment of 50 

Nasal 112 

Nervous no 

Neuralgic 78 

Neurasthenic 105 

Of Exhaustion 107 

Of Menopause 23 

Of Meningitis 17 

Of Lithaemia 65 

Operations on Ocular Muscles for Relief of . . . . 112 

Organic 55 

Ovarian . 105, no 

Pathology of 1 

Sexual 24 

Sick 21 

Sub-occipital .. ... 8 

Toxaemic 65 

Uterine 2 

Uraemic 71 

Varieties of 1 

Veratrum Viride in 7 

Vibratory 113 

Anaemic 33 



— 119 — 

PAGE. 

Headache, Anaemic Absinthe in 43 

Albuminate of Iron in 38 

Cases of . 33 

Chartreuse in 43 

Citrate of Caffeine in 49 

Cocaine in 41 

Fothergill on 34 

General Faradization in 53 

Hypophosphites in 40 

Injection of Dried Blood in 54 

Iron in 39 

Marshall Hall on 45 

Metrorrhagia in 34 

Nasal Stenosis as a Cause of 44 

Nitrous Oxide Gas in 50 

Opium in 42 

Symptoms of 33 

Strychnia in 39 

Congestive 5 

Alcohol in 28 

Arsenic in 16 

Cardiac Hypertrophy 14 

Climate for 32 

Cod-liver Oil in 14 

Diet in 26 

Galvanism in 30 

Ergot in 16 

Meat Diet Harmful in 14 

Meningeal 17 

Mercurials for 15, 16 

Phosphates in 10 

Pressure 29 

Pulse in 15 

Symptoms of 5 



120 

PAGE. 

Headache, Congestive, Turkish Baths in 24 

Conjestive 5 

Alcoholic 5 

Alkaline Baths in 11 

Aperient Water in 6 

Bromides in . . 6 

Camphor in 9 

Cupping in 12 

Cutaneous Revulsion in 9 

Exposure to Sun, from 7 

In Anaemic Patients 7 

Packing 12 

Purgatives in 15 

Veratrum Viride in 7 

Head Evil 105 

Head Symptoms no 

Herpes in Neuralgia 81 

Hydrencephaloid Condition 45 

Hungarian Waters 25 

Hunyadi Janos Water . . •. 25 

Hysterical Headache 105 

Infra-orbital Neuralgia 78 

Intra-cranial Neuralgia 81 

Introduction 1 

Insolation, in Cases of 7 

Iodoform : 49 

Iron, Albuminate of 38 

Koumyss 52 

Liniments 30 

Lithaemic Headaches 65 

Lemaire Picquot on Arsenic 16 

Left Ovary, Hyperaesthenia of 107 



121 

PAGE. 

Lemonade, Phosphoric Acid 108 

Localization of Head Pain 2 

Malarial Headaches 74 

Malate of Iron 37 

Massage of Scalp 93 

Matzoon 52 

Meckel's Ganglion, Removal of 100 

Methyl Chloride 90 

Meningeal Congestive Headache 17 

Meningitis, Headache of 59 

Migraine 19 

Ammonia Muriate in 22 

Angio-paretic 20 

Angio-spastic 35 

Association with Epilepsy 20 

Bromo-caffein in 22 

Bromides in 22 

Coffee in 22 

Chloral in 22 

of Children 46 

Routh's Formula 23 

Symptoms of 20 

Treatment of 22 

Mortimer Granville's Apparatus 91 

Nasal Bleeding 18 

Nasal Headache 112 

Nasal Stenosis 44 

Needle Bath , 26 

Neuralgia, Aconite in ...-.-. 83 

Actual Cautery in 87 

Ammoniated Copper in 85 

Antipyrin and Antifebrin in 84 

Belladonna in 87 



122 

PAGE. 

Neuralgia, Bi-sulphide of Carbon in 87 

Chloride of Ammonia in 85 

Chloride of Methyl in 90 

Cimicifuga in 85 

Cocaine in 87 

Croton Chloral in 84 

Divisions of 78 

Division of Infra-dental Nerve in 98 

Donovan's Solution in 86 

Electricity, Static in 95 

Ether Spray in 90 

Frontal 7S 

Gaiffe's Disk in 95 

Galvanism in 94 

General Treatment of 85 

Herpes in 81 

Intra-cranial 81 

Local Treatment of 87 

Methyl Chloride in 90 

Moist Pack in Q5 

Neuro- Paralytic Ophthalmia in 8r 

Nerve Stretching in 96 

Nitrous Oxide Gas 39 

Ointment for 87 

Osmic Acid in . 89 

Phosphorus in 86 

Refrigeration in 90 

Supra Orbitral 79, 81 

Sub-occipital 86 

Tonga in 85 

Trophic Disease in 81 

Tr. Actea Rac in 85 

Use of Cold in 90 

Veratria in 87 

Vibratory Treatment of 91 



— 123 — 

PAGE. 

Neurasthenic Headaches 105 

Nervous Headaches no 

Ointments 87 

Organic Headaches, Belladonna in 59 

Diagnosis of 55 

Ergot in 59 

Ether Evaporation in 59 

Head Coil in 58 

Operation on Eyes for Cure of Headache 112 

Osmic Acid Injection 89 

Ovarian Headache 105 

Phosphorus 86 

Pathology of Headache 1 

Percenter 92 

Percussion of Skull 62 

Periostitis of Alveolar Process as Cause 103 

Phosphorus, Thompson's Solution of 87 

Phosphoric Acid Lemonade 108 

Pharyngeal Granulation as Cause of Neuralgia 103 

Physostigma n 

Prosopalgia 98 

Purgation 25 

Quiet Gout 68 

Rectal Injections of Assafcetida 106 

Dried Blood 54 

Salicylate of Soda 69 

Salol 70 

Scalp, Faridization of . . 93 

School Children, Headache of 12 

Sick Headache 21 

Sexual Headache 24 



— 124 — 

PAGE. 

Solution, Fothergill's 23 

Routh' s '. 23 

Springs, Mineral 24, 25 

Strophanthus 108 

Strychnine, Arseniate of , 108 

Supra-Orbital Neuralgia 81 

Surgery Cerebral 64 

Sympathetic Headache no 

Syphilitic Headache 56 

Large Doses of Iodide in 57 

Tic Douloureaux 95 

Gelsemium in 95 

Nitro-glycerin in 95 

Neurectomy in 9S 

Nerve Stretching in 96 

Tonga 85 

Toxaemic Headache 65 

Tobacco as Cause of 76 

Trigeminal Neuralgia 78 

Trophic Disorders in Neuralgia 81 

Tumor as Cause of Headache 60 

Uraemic Headache 71 

Symptoms of 71 

Diet in 72 

Tri-Nitrine in 73 

Use of Cold 28 

Ophthalmoscope in Diagnosis of Headache 62 

Valerianate of Ammonia ;. ... 106 

Vulpian's Case 82 

Wax in the Ear as Cause 111 

Wire Brush 94 

Woakes on Headache 8 



